Up through the 1970s, the distribution of medical colleges in India across the country's 28 states was more or less equitable. That's because nearly all the schools were in the public sector, funded by the state or federal government and regulated by the Medical Council of India (MCI). But in the 1980s--in response to a rising demand for doctors, a loosening of economic and regulatory restraints, and constitutional loopholes--India's leaders increasingly began to allow privately controlled trusts to found medical schools. That's when "the system completely changed," says Ajay Mahal, assistant professor of international health economics at the Harvard School of Public Health (HSPH).

Within a few years, businessmen and expatriates with deep pockets looking for an "investment" and local politicians looking for an easy source of income and to keep their constituents happy were opening medical schools. A casual examination of the names of medical colleges in India reveals a Who's Who of local political heavyweights.

In theory, loosening government restrictions on private funders might seem like a good idea for a nation of over one billion people with a barely functioning national health system, and only 646,000 physicians--.6 per 1,000 people, according to a 2005 World Health Organization report. More schools would mean more doctors and affiliated hospitals. And many more patients would receive health care and the benefits of public health programs designed to control, say, AIDS and TB, or to improve child nutrition.

But in reality, the poorest, neediest states were left with a paucity of schools--and a medical education system that now has major quality-control problems. That's the conclusion of a study of the explosive proliferation of medical schools in the last 50 years by Mahal and his coauthor, Manoj Mohanan, MPH '00, MS '04. With their findings, which will be published this fall in the journal Medical Education, the researchers hope to help India redress an inequitable distribution of health-care providers and services.

DECIDEDLY LOPSIDED
In 1970, there were 89 public medical colleges and 10 private colleges in all of India. But between 1970 and 2005, the researchers found, the number of public colleges grew by 42 percent, to 126 institutions. Meanwhile, private schools multiplied by 1,120 percent, to 122 institutions, while claiming a roughly equal share of the more than 26,000 seats in total.

But numbers alone, Mahal and Mohanan caution, don't tell the whole story.
The private schools' distribution is now decidedly lopsided: 79 of the 122 colleges are sited in just 4 of the country's 28 states. All four of these states are in the south or west of India, and all have above-average incomes.

That leaves relatively few hospital beds in states with the poorer--not to mention less healthy--half of the population, and too few doctors, since medical school graduates tend to put down roots where they've trained. In 2001, 75 percent of all new-physician registrations in India were in the richer states--likely a reflection of the upsurge of medical colleges there, Mahal says. Yet according to WHO, in the countryside, where nearly three-quarters of the population lives, one doctor may be responsible for as many as 200,000 people.

Moreover, the HSPH researchers note, the private schools are sloppily regulated, and the quality of education is irregular. Students may be admitted more for what's in their families' pocketbooks than for what's in their heads.

"Today, there are maybe two private medical institutions that you would hold up as paradigms of excellence," says Mohanan, who graduated from a public institution, the University of Bombay's Grant Medical College, in 1998. "For the most part, the public-sector institutions are much, much better."

Getting into them is also much tougher. All seats in public colleges, which cost about $2,000 apiece, are awarded based on merit. Fifteen percent of them go to out-of-state applicants based on scores on a national entrance exam; the remaining 85 percent go to in-state residents based on scores from state exams. By contrast, only half the private seats are merit-based. (In a move toward greater equity in physician education, legislation now on its way through India's parliament will, if passed, require public medical colleges and other federally funded institutions to reserve half their seats for applications from India's so-called backward castes.)

"When I went to medical school I had fairly good grades, so I could get into Grant Medical College based on my state's quotas," says Mohanan. "But if I'd wanted to get into the same school based on the national quotas, I wouldn't have had a snowball's chance."

CORRECTIVE MEASURES
From the patient's perspective, the repercussions of the burgeoning private sector are dire. Many private medical schools have bare-bones faculties and minimal hospital capacity--not to mention seats for hire ("you pay, we find a way"), which go for as much as $30,000. According to news reports, including one in the July 15, 2002, issue of Healthcare Management Express, which covers India's health-care industry, some schools have been known to pay locals to pose as hospital patients when the MCI made its rounds, artificially inflating the number of occupied beds in order to meet accreditation requirements.

Reforming the system won't be easy. The researchers propose four corrective measures: national exams to monitor performance across colleges; a government-controlled ranking of all institutions; a public posting of admissions standards; and stiff sanctions for institutions that break the rules.

The bottom line, though, is that India's government must open more public medical schools. "There is no getting around it," says Mohanan.

Thea Singer writes about science, public health, business, and the arts. Her work has appeared in the Boston Globe, Washington Post, Harvard AIDS Report, Natural Health, Inc. magazine, and TechnologyReview.com.

Photo: Kent Dayton-HSPH