The Real NEET Scam: Is India's Medical Exam Failing Healthcare Needs?

4th June 2024 in India saw not only the declaration of the much-awaited Lok Sabha election results but the results of the NEET UG medical entrance exam as well. This exam, attempted by around 23 lakh students, was highly competitive and is likely to provide only admission to around 1 lakh students nationwide. Amid allegations of several perfect scores from the same exam center, paper leaks, and mathematically impossible marking irregularities, the #NeetScam2024 scandal has erupted, casting doubt on the integrity of the National Testing Agency (NTA). Protestors claim the NTA is sabotaging the futures of aspiring doctors, potentially crippling India's already strained healthcare system. But the real question is: Is the NEET system truly designed to meet India's diverse healthcare needs, or is it setting up future doctors to fail?

The urban-rural divide in healthcare

When we talk about Indian healthcare and our doctor-patient ratio, most of us forget that the numbers are more complicated than they seem off the bat. Sure, India has achieved the WHO recommended standards for the doctor-patient ratio, standing currently at 1:834, compared to the standard 1:1000 (however, this includes AYUSH practitioners).

But this does not translate to quality healthcare for all, because most doctors are concentrated in a few urban hotspots. This leaves large swathes of areas in rural India woefully under- or unserved. A 2016 article says that 80% of doctors are concentrated in cities serving 28% of the Indian population.  This is the problem that should take priority as we try to achieve efficient and quality universal healthcare delivery. 

But this also indicates that increasing the number of medical seats is not the solution for doctor shortage. We need to look at why the urban concentration of doctors is happening and address that.

Sprint or marathon

“The nightmare that is preparation for NEET UG, NEET PG and the grueling requirements of the PG course ensures that many of us are burnt out at the start of our careers,” says an internal medicine consultant who wishes not to be named. “I have not met one colleague who has been through this system and says I am willing to put in a few more years of effort in an underserved area. Doctors tend to prioritize having an easy life as soon as they get to the stage of independent practice and they start focusing on earning money to facilitate that.” 

Everybody who runs long distances knows that you do not use up all your strength and speed at the start of running a marathon. The energy you conserve by pacing yourself through the race is what allows you to be able to run long enough to finish it. However, the NEET examinations- both UG and PG- require mammoth efforts and preparation. The MBBS and PG courses that follow also work on the arduous principle of trial by fire, which leaves doctors completely burnt out by the time they can start working independently. An urban location offers them more opportunities for socialization, leisure and fun along with easier set ups and better facilities for practice, which they may then easily embrace.

Return of investment

The other problem is the cost of entry to medical education is too high. This might not even include the sky-high fees that are charged by some private colleges (60 lakhs to 1 crore on average). Indirect costs such as the time spent in coaching, the time taken as drop-years and mental health issues brought by pressure  serve to ensure that doctors want to ‘earn back’ all that they have ‘spent’ on the route to becoming a doctor.

Sure, NEET exams have done away with the malignant problem of capitation fees, but they have introduced more silent and insidious financial losses in their stead. When one has to spend this much money to become a doctor, the only rational reaction from their end seems to be to use that degree to earn more money.

Competence and cultural competence

The second issue with the NEET examinations is that it is drawing people away from meaningful clinical learning and practice and making them spend their time solving MCQs. The MBBS curriculum aims to produce doctors who can function competently as primary care physicians in areas of need.

However, students these days are found to be bunking practical classes and internships to watch coaching videos for PG preparation. This results in them not learning basic skills such as inserting an IV line or doing an ECG. By the time they get their degree and could be starting an independent practice, many of them have critical deficiencies in important lifesaving skills such as performing CPR or vaginal deliveries. 

A survey was done by Dr Srimathi, an independent health researcher and Dr Anand Zachariah, a professor of internal medicine at CMC Vellore among medical students and they found that only 44% of medical students they surveyed felt that they would be able to function competently as a primary care physician after their MBBS degree. In the survey, they also noted a significant perspective shift among these students who have now started perceiving MBBS as just a stepping stone towards postgraduate medical degrees and have begun replacing their textbooks with PG coaching material. This problem has also been highlighted by a previous Nivarana article here.

“The other issue is that these MBBS graduates might initially try to work and study for NEET at the same time, but if they do not qualify once, their reaction is to quit their jobs and study full time. This too takes doctors in large numbers out of the workforce,” says another Internal medicine consultant. “It is truly amusing that a country with a dire need of working doctors in rural areas has designed a system that would produce people who will not be able to fulfill that need.”

Cultural competence is another thing that is found lacking among doctors thanks to the current system. Seat distribution via NEET ensures that states are not completely in control of their seats. The 50% of seats in control of the central government can be filled by candidates from the same or different states. When candidates from different states come to study in a particular state, they may have issues connecting to the local populace and attaining cultural competence (understanding the motivations and history of the people one is working with). This might also lead to people who do not care enough about the people they are working with to help in their upliftment.

The recent complaints of North Indian MBBS students in AIIMS Madurai (Tamil Nadu) that their patients do not know Hindi and that they aren’t getting a holiday for Holi is an example of how seat allocation via NEET puts up a barrier towards cultural competence.

The principle of exclusion

NEET in its current form is a highly exclusionary exam which is designed to keep underprivileged and marginalized people out of the system. Though operating on the myth of merit – it allows private college seats to be accessible to lower-scoring students who can pay large amounts of money while a student who has scored higher but cannot pay is left without a seat. 

In fact, a mathematical analysis of NEET counseling and seat allocation systems reveal that luck and probability play far too much a role to ascribe NEET victories to merit. The amount of money required for coaching and the concentration of coaching centers in cities also ensures that it is gatekept from students from poor backgrounds. This too has been instrumental in weakening the public health systems of the country.

In an interview, Dr. Palanivel Thiagarajan, the minister of IT and digital services in Tamil Nadu points out that universities in the Global North have been decreasing weightage of marks scored in standardized tests for college admissions as there have been numerous studies which show that standardized tests have an inbuilt bias of favoring privileged populations. His arguments are supported by multiple studies done from the Global North. 

An article written in the New Indian Express about Anitha - the girl who spearheaded Tamil Nadu’s opposition against NEET in the Supreme Court, who eventually died by suicide in 2017 talks about how Anitha had never used a computer in her life and had to be taught the basic functions using a friend’s laptop. “When she went to the center for JIPMER exams, she didn't even know how to switch on the computer as she hadn’t seen a CPU before”, her brother had told the reporters in that article. This reveals the stark reality of exactly how exclusionary the medical entrance exams are. 

 “When I visited Mahabalipuram, I had the opportunity to visit the PHC. It was unstaffed,” I remember a senior colleague telling me. “The last time it was staffed was when a doctor from the area had come back after doing their MBBS course and served there.” This is one of the most important reasons to provide opportunities for the marginalized – as they have an emotional attachment towards their communities and will hence come back to serve them. “People from an area will also feel more comfortable availing care from a person they know and trust, so it’s really important to ensure representation,” added the senior.

Potential solutions

The states that make up India are unique and different from each other and hence decentralization of health as a subject is important. It allows states to make decisions that help in strengthening their public health systems and filling in the gaps. One of those decisions is whom to admit into their medical colleges and train to become doctors. A single entrance exam diminishes a state’s ability to give representation to its underprivileged and marginalized populations and must be reconsidered. In the long run, decreasing the weightage of standardized testing marks in the admission procedure to colleges may be attempted.

Incentivising rural service – such as financial incentives, better housing and working conditions for doctors willing to serve in rural areas along with mandatory rural service postings for seats availed from the central government counseling could also be implemented.

Including a section which covers practical clinical aspects of medicine along with procedural skills and community awareness in PG entrance exams might also incentivize MBBS students to gain those meaningful skills.

The NEET exams, in their current form, prioritize rote learning and financial capability over genuine medical competence and commitment to serving the underserved. This systemic flaw leads to an urban-centric concentration of doctors, burnout, and a lack of practical and cultural competence among new doctors. The result is an exclusionary system that fails to meet the healthcare needs of India’s diverse population. And this is the real NEET scam we need to be wary of.

Edited by Radhikaa Sharma.

Image by Gayatri Sharma.