The government reportedly spends around Rs 31 lakh a year on an undergraduate student at New Delhi’s All India Institute of Medical Sciences against an annual fee of about Rs 5,000 only. Indian Institutes of Technology charge around Rs 2.5 lakh per annum, well below Rs 3.5-lakh that the by Birla Institute of Technology and Sciences, a private institution, asks.

What explains this wide gap in what the government spends and the tuition fee a student pays? And, why should the exchequer, taxpayers in turn, be burdened with this additional expenditure? This is true not just of the government medical and engineering colleges but also those imparting degrees in social sciences. Management institutes, however, are trying to narrow the gap. Schools such as Indian Institutes of Management are gradually moving to a fee structure that is closer to the expenditure incurred.

The need to subsidise higher education is a point of debate. In a number of countries, like the United States, higher education institutions fend for themselves. There is no across-the-board subsidy though targeted financial help in the form scholarships and low-interest loans do exist. There is a move in this direction in some of the higher education institutes in India as well. In a number of institutes abroad, international students cross-subsidise the domestic ones but without burdening the exchequer.

So, the question: should students whose education is subsidised by the government be obliged to do public service?

Let us take the case of healthcare in India. In 2006, only 26% doctors worked in rural areas, where 72% of Indians live. In 2010, the now-defunct Planning Commission reported a shortage of 600,000 doctors. It is a fact that a number of primary healthcare centres, a citizen’s first point of contact with public health system, are without doctors. Medical colleges are churning out a large number of doctors—though still not proficient enough to meet international standards—there is a reluctance on the part of these doctors to serve in rural or interior areas. Thus, we have a situation where on the one hand, the government is massively subsidising education of these doctors, on the other, there is a shortage of doctors where they are needed the most.

Apart from fulfilling a social obligation, there are a number of advantages in making rural service obligatory for doctors graduating from government medical colleges. The exposure to rural and tribal communities, which most of them know little of, will professionally benefit students, widening their horizons.

They will benefit financially as well. The emoluments given to the students would not be as interns but as doctors during the time they spend in rural areas.

Not just them, but the areas they service will also benefit, both directly and indirectly. Their presence would mean a boost for local and larger economy, as they would need a place to live and eat. They would need equipment, drugs and even staff to run a smooth operation.

A large number of countries have made it compulsory for doctors to spend a certain period of time in designated areas. The erstwhile Soviet Union introduced the system in 1920. Countries like Mexico (1936) and Norway (1954) adopted it in some form. It was in the 1970s that the system really picked up. Around 70 countries follow this model in one or the other form, the Bulletin of World Health Organization said in 2010. In Australia, all international graduates must spend 10 years in “district workforce shortage”. Pharmacy students in New Zealand are required to undergo a rural “externship” during training. Graduates in Vietnam and Mongolia have to go to underserved regions if they want to go in for higher education.

The WHO study, which outlined the impact of obligation of public services, concluded that in Indonesia, it increased doctors’ willingness to serve in remote areas. Turkey’s programme was effective in mitigating staffing discordance. There were reports of better staffing in rural areas in South Africa bringing down the waiting time for patients. In Thailand, it helped narrow the disparities in urban and rural health worker density. Most places seem to have benefitted from obligatory services.

Of course, a lot also depends on the manner in which such obligations are formulated and mandated. There could also be operational issues as well as problems with enforcement. These are minor arguments when seen against the larger picture. Public service is a social obligation on account of the subsidy accruing to the beneficiary. India desperately needs a healthcare boost where shortage of staff, especially doctors, in rural areas is acute, adversely effecting health delivery.

Lastly, experiences of both the developed and developing countries have sufficiently demonstrated that such an obligation has had a positive and far-reaching impact. Therefore, yes, those receiving subsidised education should be asked to do public service.

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