Modern (medical) education – A tale of two goddesses?

The Goddesses, Saraswati, Lakshmi and medical education

However, in some ways, these goddesses are more allies than competitors. In idols and images, you will always see them seated on both sides of Lord Ganesh, the God of wisdom. He is the connecting link between the two goddesses.^[1] One of our mentors often mentioned the close bearing of these legends on modern-day education.

The authors have long experience in undergraduate medical education in Nepal and India. Saraswati and Lakshmi appear particularly relevant to modern medical education in these two countries. An institution of higher learning imparts knowledge, and clearly, Saraswati ought to be the reigning deity. However, every institution also requires money for its functioning and cannot run without the support of Lakshmi.

Conventionally, medical colleges and many other educational institutions were run and supported by the government or charitable, not-for-profit organizations. Health institutions also provide healthcare to patients, and governments spend substantial amounts on patient treatment. Here, while the “Lakshmi aspect” may not be immediately evident, government money is mostly provided by the taxpayer. Direct taxes are paid mainly by the more well-to-do, and indirect taxes are paid by everyone. While these colleges can provide education to students at subsidized costs, they often complain of a lack of funding to acquire the latest equipment, and long waiting times to implement change due to red tape.

In recent decades, there has been an explosion in learning, and access to education has, been largely democratized. Besides the government-run institutions, there are also institutions run by for-profit organizations. The first private medical college in India was started in 1953.^[2] Since then the proportion of private medical colleges in India has risen and is now almost equal to that of government medical colleges.^[3] Most of the private institutions want to be profitable and worship Lakshmi. They initially attracted negative press and were termed “capitation fee colleges.”^[4] They were accused of compromising on student quality and merit. In recent times, the more progressive private institutions have also realized that to be successful, they must provide education of a high standard to remain competitive.

With population growth and increasing demand, there is a ready market for self-financing institutions. In many Indian states, private for-profit professional colleges were not encouraged for a long time, but now self-financing colleges are functioning throughout the country. Student fees are the major source of revenue for many of these institutions. In Nepal, groups from India were invited to start private medical institutions during the early 1990s.^[5] The present data show that Nepal has 24 medical colleges, and 17 are in the private sector.^[6] The situation is not black and white, with private colleges being cast as villains. However, these colleges produce educated professionals without a drain on the public exchequer.

A fear has been expressed that the quality of education may be sacrificed, and students may graduate more easily from self-financing institutions, considering that they are paying candidates. Some institutions may dilute academic standards to attract more paying candidates.

Students from government health professions, engineering, management, and other colleges often migrate to developed nations after completing their courses. This issue has attracted a lot of attention and has been called developing nations subsidizing the healthcare of developed ones.^[7] How many years should professionals work in their country of origin before they can migrate? How can these persons continue to contribute to their country of origin? A recent paper takes a middle position between the extremes and calls for a more moderate approach to migration.^[8] In these instances, Saraswati and Lakshmi may be migrating together from a poorer region to a richer one.

It is here that the role of Ganesh, the God of wisdom, comes in. It must be remembered that nearly all countries have mechanisms for assuring the quality of professional education. These can include external examiners, exams being conducted by a university, all graduates being required to pass a licensing examination before they can register for practice, and accreditation, among others. A recent article mentions that some African countries still must develop accreditation systems, but international cooperation and the quality of accreditation are improving globally.^[9] The more established institutions have realized the importance of maintaining good academic standards. Many also invest substantially in new teaching-learning modalities and in faculty to provide high-quality learning experiences. The world is changing faster than ever before, and educational institutions have an important role to play in helping students face these challenges.

Investing in learning facilities and new teaching-learning resources is important. There is a need to attract and retain competent faculty. In many institutions, faculty may not be rewarded adequately, and they spend time in private practice and outside tasks, such as working in coaching or tuition centers. Working toward quality requires an adequate number of faculty, and merely inducting a minimum number of staff members is not ideal.

The issue of what an institution should charge for the academic program is also important. In many instances, due to various reasons, especially in government-owned institutions, the fees may not have been revised for a long time. College fees may be a politically charged decision in many places. The institution in this case may not have the resources to provide a high-quality learning experience for students. In certain cases, this can be addressed by funding from government bodies or non-profit agencies. However, during hard economic times, governments are also in a financial crunch, and in many developing nations, the expenditure on education is low. The fees charged should be adequate to meet the institutional requirements for growth and development. Institutions should highlight the reasons why they are charging a particular fee and link it to the strengths of their program and the facilities provided by their institution.

Government agencies and regulators have an important role to play in ensuring that high-quality education is provided, and institutions provide value for money. Students and their guardians should have access to objective, impartial information when deciding on an institution and a course of study. For health professions institutions, the needs of underserved areas for health professionals and students, and the practitioners’ desire for growth and development should be balanced. With economic growth, an increase in purchasing power, and demand for skilled professionals, self-financing institutions will continue to develop and grow.