Medical education: at what cost?

Medical education: at what cost?

Throughout the world medical education has become increasingly expensive. Vijaya Raj Bhatt considers the repercussions for students as well as public health The cost of medical education in comparison to the poverty level

The World Bank has set the international poverty line at $1 for every person a day. People considered to be living in “absolute poverty” if their income is below this line. By this measure, 1.2 billion people are currently living in absolute poverty in developing and transitional economies.1 The Human Development Index shows that even in affluent industrial countries, 7-17% of the population is poor, which adds more than 100 million people to this number.2

Although poverty is rife throughout the world, the cost of medical education remains high in developed and developing countries and is set to rise further. Research conducted by the Association of American Medical Colleges in 2004 has shown that the average tuition fees at state medical schools during the 2003–4 academic year amounted to $16 153, and the corresponding figure for private schools was $32 588. In the 1984-5 academic year, average tuition and fees were $3877 at state medical schools and $12 973 at private ones. In 19 years, the cost has therefore increased by 317% and 151%, respectively. Further, adding $20 000- $25 000 for living expenses, books, and equipment brings the estimated cost of four years of attendance to about $140 000 and $225 000, respectively.3 This continuing escalation has been accompanied by an enormous increase in the average debt of graduating students. Furthermore, applications to medical schools have dropped from about 47 000 in 1996 to 35 700 in 2004.3

In a developing country such as Nepal, where 31% of the population lives below the poverty line4 and where the income per head is $240/year (in 2003)5 6,a medical degree costs $25 000-$55 000 in total.7 8 9 This is more than 100 times the amount that an average Nepalese citizen earns in one year.

In the United Kingdom, even after receiving a full grant, medical students are expected to qualify owing a total of about £10 000 ($16 355).10

Effect of the high cost of medical education

Affordability

Because of such high costs, medical education is not affordable to most of the world's population. The system does not respect the educational right of poor people.

Further, escalating costs of medical education (and education generally) are leading to its progressive privatisation: in North America, medical education is already privatised, and rising co-payments are a feature of higher education in many other countries, such as the UK and Australia. This trend threatens to return medicine to a preserve of the wealthy.11

The research conducted by the Association of American Medical Colleges reflected this situation: for the past two decades, 60% of medical students have come from families in the top fifth of income, with the bottom three fifths together accounting for about 20%.3 The same is true for Canadian medical schools, which have fewer students from low income families in general. 12

The higher the cost of medical education and higher its rise, the more inaccessible such an education will become for good applicants from low income families.

A national survey of underrepresented students done by the same association indicated that the cost of attending medical school was the main reason they did not apply. 3

This may have a negative effect on the quality of medical doctors and service they provide. People from families with a low socioeconomic status will be under-represented in the medical profession. Training such students has limited value from public health point of view because many of them look for entry into a wealthy country and leave the country where they were trained—a trend that has increased in developing countries such as Nepal. This is why it is critical to extend medical education beyond the wealthy to reach poorer sections of society, who are more likely to serve their own communities.13

Lack of ethnic diversity

The high cost of medical education has also prevented national efforts to increase ethnic diversity in the doctors' population in many countries. African Americans, Hispanic Americans, and Native Americans make up 25% of the US population, but they account for only 11% of medical students, and, although one in eight Americans is black, fewer than one in 20 doctors is black.14

A lack of diversity in medicine affects patient care, particularly for medically underserved populations. Medical students from under-represented minorities and those from economically disadvantaged backgrounds are more likely to enter primary care fields, practice in rural communities, work in economically depressed areas, and treat patients from ethnic minorities.14 Decreased access to education for aspiring doctors from minorities translates to a lack of access to medical care for underserved populations, further exacerbating the crisis in disparities across the country.14

Cost management strategies

In different parts of the world, students use different methods to manage the cost of their medical education.

Part time employment

In many parts of the world, including the UK, students manage the fund by working—for example, in waitressing or as a bar attendant. In some countries—for example, Portugal—part time employment is almost impossible because working patterns are inflexible. Finnish students, on the other hand, can do flexible part time work because of their flexible duty schedules. Students can work two or three hours a day and have relative freedom to choose which days they worked. However, in many parts of the world—students rarely work and study at the same time.10

Financial support


In Portugal, every couple with children who are studying is given money by the social security service, dependent on parental income.10 In Nepal, India, Pakistan and many other countries, scholarship programmes are available in public and private medical schools.7 8 9 10In Egypt, medical education is mostly funded by the government.10

Self financing colleges

In Nepal, self financing medical colleges are being encouraged by the government, which do not receive government aid and have to build their own infrastructure. Various government committees monitor and enforce internationally developed standards for the facilities and education offered by these medical colleges. Although the committees do not regulate the fee structure of these self financing medical colleges, the government controls the selection of 20% of the student body who, chosen on the basis of merit, will receive free medical education.13

Institutional financial programmes

In some parts of the world, residency programmes and other part time jobs are offered by medical institutions themselves. French medical students get paid during their clinical years, and Belgian ones are paid to do on-call shifts. Finnish medical students are paid for both.10 However, these programmes are largely lacking in Nepal.

Educational loans

In developed countries such as the UK and US, as well as in developing countries such as Nepal, India, and Pakistan, provision is made for educational loans, for which, however, interest rates are high. Indian banks have student loan schemes, but a bright student from a poor family could apply for a government sponsored national scholarship. Egypt has no student loan scheme, except country grants cashed by poor students once during the first year. These grants cover only tuition fees.10

Increased amounts of educational debt

The medical education sector has become expensive, and these increases mean that students have to invest substantially in their education and may even run up sizeable debts. The number of graduates with debts and the amount of these are on the rise in most parts of the world.

More than 80% of graduates in the US have high debts on completing their education.14 A study has shown that at Thomas Jefferson University, 36% of the medical students graduating in 1992-3 had debts of at least $75 000, more than three times that in the classes graduating in 1987-9.15

Influence on specialty choice and choice of practice location

Research in various parts of the world—albeit not in developing countries—has shown that a high level of educational investment and debt has a negative effect on family practice, specialty choice, and careers in primary care.3 12 15 16 In America, the number of medical students pursuing careers in primary care has fallen and the numbers seeking careers in radiology, orthopaedics, ophthalmology, and dermatology, which offer higher incomes, have risen.3 An internet survey of all students at Canadian medical schools has shown that Ontario medical students expect a large increase in their debt on graduation, an increased consideration of finances in deciding what or where to practise, and increasing financial stress. Financial considerations were found to have a major influence on both specialty choice or practice location.12

Implications for primary health care

An increase in the number of students with high debts affects the selection of a career in family practice.15 Particularly for developing countries, this would mean that an increasing number of people would give up general practice. Diversion from primary level health services to specialised health services results in service to less of the population and at a high cost. High costs of medical services limit their use by poor people, resulting in an unfair distribution of health services to populations from different economic strata. Health would be out of the reach of common people with fewer resources and low budget allocation to health. Health outlets will be centralised to urban and developed parts of the country as is seen in Nepal, and rural areas will be devoid of health services because they are unable to pay. The health right of the marginalised and underprivileged part of the population cannot certainly be preserved in such a situation.

Studies have shown that in developing countries doctors often do not want to go to rural areas. The UN Development Programme, Human Development Report 2003, mentions an average ratio of four doctors per 100 000 people (with a total of 3200 doctors in 2003), and one doctor per 150 000 people in remote areas.17 Most of the doctors are concentrated in the city, 18 and they are often not willing to go to the villages, hence the health posts and the primary health centres in the rural areas are staffed by community health workers.19

Conclusion

The high cost of medical education is a complex problem. Although many strategies are being applied in different parts of the world, they are not very successful. Medical schools, government and the public themselves should join their effort to solve the problem.

There is no universal solution, thus various sectors of society should apply various approaches to structure these financial responsibilities.

Competing interests: None declared.

Vijaya Raj Bhatt, final year MBBS student, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal Email: vj@iom.edu.np


Published in studentBMJ 2006;14:265-308 July ISSN 0966-6494