Why Does Tamil Nadu Oppose National Eligibility cum Entrance Test - Undergraduate?

Before we address the larger question of why Tamil Nadu, a state in India, opposes the use of National Eligibility cum Entrance Test - Undergraduate (NEET- UG) to select a cohort every year, from which students are chosen for admission to undergraduate medical education in nearly all medical institutions in the country, let us start with the fundamental question of the purpose of medical college and why should state government be in the business of running the medical colleges. In any country, more so in developing countries, the health of its citizens is the de facto responsibility of the state. The Constitution of India, through its Article 21, protects the 'right to life', in turn presupposing a basic right to access reasonable healthcare.1 The Indian constitution identifies the subject of 'Public Health' as a subject on which the State Government can legislate almost exclusively.2 In India, the states, through its public health departments, are constantly engaged in offering reasonable preventive and curative services, to elevate the quality of life of its citizens. Even before independence, public health was in the domain of the presidencies, for example, the state of Tamil Nadu (erstwhile Madras Presidency) legislated its Public Health Act as early as 1939.3 During then, the trained doctors formed an integral part of the state infrastructure to ensure public health, with the establishment of hospitals and the involvement of doctors in sanitation, vaccination and prevention of communicable diseases.4,5 Here, the medical colleges run by governments play a critical role in producing quality health professionals, to be part of the state health infrastructure, whose mandate is to ensure public health. For example, the State Government of Tamil Nadu runs government medical colleges, which train health professionals who can provide primary, secondary and tertiary medical care. Therefore, viewing the medical colleges through a lens of 'higher education institutions' which produce medical graduates is, at best myopic, and lacks the systems thinking perspective, that allows one to visualise the strong link between the constitutionally mandated 'right to life', public health and medical education. With the horizon provided by the constitution to the states in the domain of 'public health', Tamil Nadu embarked on a long journey of creating state medical colleges in every district with the aim of broadening the availability of tertiary medical care to its residents. To produce the necessary human resource to sustain the state's medical infrastructure, the state went on to set up 35 government medical colleges, making the state one with the largest number of government medical colleges. Given the role played by the state government medical colleges in sustaining the public health infrastructure, one can appreciate the state government's need for freedom, i.e., state autonomy in the selection process of government medical colleges at undergraduate, postgraduate and super speciality training levels.6 THE EXPERIMENTS OF TAMIL NADU WITH SELECTION MECHANISM Tamil Nadu, before 1984–1985, had a system of considering the higher secondary examination marks along with the interview system, with the weightage given to the marks secured in the interview, for the selection of candidates for the medical colleges. Due to the mounting criticism regarding arbitrariness, corruption and favouritism, the then Tamil Nadu Government scrapped the interview system and replaced it with Tamil Nadu Professional Courses Entrance Examination (TNPCEE). The resultant system gave equal weightage to the marks secured in TNPCEE and the marks secured in the core subjects in the higher secondary examination.7 Later, in 1989, the Government of Tamil Nadu introduced the system of improvement examination, a practice of allowing students who have passed their higher secondary examination, to appear for select subjects to improve their performance. 20 years of selecting students revealed this fact that students who had time and resources to prepare for TNPCEE and who were able to take multiple attempts for select subjects through improvement examinations crowded out students who were disadvantaged due to economic conditions and socio-economic backwardness associated with their caste. This reality was reflected in a clear sense through the data from 2004, where it was revealed that 4793 students took improvement examinations out of an estimated 500,000 students, and they ended up cornering more than half of the seats in medical colleges in the state.8 The skewness imposed in the selected cohort for medical colleges became a key topic of discussion in the public sphere in Tamil Nadu, and several political parties agreed on the need for the TNPCEE and the improvement examination to be scrapped. In 2006, the Government of Tamil Nadu constituted an expert committee, under the leadership of Prof. Anandakrishnan, a decorated academic, who was then the Chairman of the Madras Institute of Development Studies and Indian Institute of Technology Kanpur, to examine the implications of the abolition of Tamil Nadu Professional Courses Common Entrance Test. The committee after analyzing the performance of students with various socio-economic backgrounds in higher secondary examination and Common Entrance Examination (CET) concluded that the entrance examination skews the competition landscape against rural poor students studying in their native language. Further, it imposes severe stress on the students who are still in their adolescence. Based on the findings of the committee, the Government of Tamil Nadu, in 2007, legislated an act that abolished the entrance examination, and it received presidential assent. The committee identified the higher secondary examination marks as a sufficient test of merit for the selection of students for medical colleges, which was agreed on by the Government of Tamil Nadu. Hence, the twin barriers of CET and improvement examination were scrapped to ensure the smooth passage of students from the school education system to medical colleges. One of the key factors identified by the committee is that the existence of an entrance examination had resulted in the emergence of a coaching class ecosystem largely in the urban areas, outside the school education system, and that the selected students through CET were largely beneficiaries of the coaching class ecosystem. While the number of students appearing for the HSC exams in Tamil medium then was more than twice that of students from English medium; it was even higher in rural areas, as high as 5:1. But the CET was largely dominated by students from the English medium, reflecting the impact of the selection pressure. It is to be noted that for MBBS/BDS, the state government has always complied with the requirement of allotting 15% of MBBS/BDS seats to All India Quota, whose admission criteria are not set by the state government. The same selection pressures also skewed the competition landscape against female students, which is reflected in the yearly statistics of similar selection examinations in India like the Joint Entrance Examination (JEE) for the Indian Institute of Technology colleges. The influence of the selection mechanism can be better explained through the stark contrast in women's representation between Anna University and IIT Madras in Chennai, which is separated by a single road named Sardar Vallabhai Patel Road. While the representation of women at Anna University is nearly equal to that of men, IIT Madras suffers from gender disparity even though supernumerary seats were created to ensure women's representation. The differentiator here is that the selection mechanism at Anna University has a significantly low participation cost, i.e., higher secondary examination, while the selection mechanism in IIT has a high participation cost, i.e., JEE.9,10 NATIONAL ELIGIBILITY CUM ENTRANCE TEST - UG: REINVENTING THE DISCARDED WHEEL "The introduction of NEET would confound the implementation of these policy initiatives and socio-economic objectives of the state since we would have to fall in line with the regulations of the national test, which did not have such enabling provisions. The national test would be out of tune with the prevailing socio-economic milieu and administrative requirements of Tamil Nadu".11 This excerpt from the letter written by then Chief Minister of Tamil Nadu J. Jayalalithaa in 2013 to then Prime Minister of India Dr. Manmohan Singh, pithily communicates the interlinkages between ensuring a level playing field for students through a selection mechanism that has low participation cost, the prevailing entrenched socio-economic fault lines in the society, the gender bias, the upwardly mobile aspirations in the society, the perceived value of government medical service positions depending on the class location of the individual and the visualisation of government medical colleges as integral to the state medical infrastructure. The unilateral imposition of NEET by the Union Government of India on the states was unique, as there was no consultative mechanism to understand the impacts of NEET on the state medical infrastructure and the socio-economic implications of this selection mechanism alongside the lack of an effort to generate empirical evidence related to the impact of the imposition of NEET in place of pre-existing selection mechanisms. Tamil Nadu was forced to accept NEET - UG, a case of reinventing the discarded wheel. NEET - UG akin to JEE is a high participation cost selection mechanism. This led to mushrooming of NEET - UG coaching centres in every major urban node in the state, coupled with the drive amongst aspiring families to enrol their kids in the Central Board of Secondary Education (CBSE) schools. While the syllabus of the NEET - UG is purported to be based on the National Council of Educational Research and Training syllabus, which provides the common curriculum for schools across India, the common knowledge amongst medical aspirants is that students from CBSE board have an edge over students studying their respective state board syllabus. Hence, there is a twin burden for the families of medical aspirants to enrol their kids in CBSE board schools whose fees are considerably higher than state board schools, and the high cost associated with NEET - UG coaching classes. The economics of the pan-Indian NEET - UG coaching class ecosystem is staggering. According to the Justice AK Rajan Committee constituted by the Government of Tamil Nadu in 2021, which studied the impact of NEET on the student community in Tamil Nadu, the business in Tamil Nadu alone is conservatively estimated to be 5250 crore rupees (630 million USD). It is common practice amongst the schools to integrate NEET - UG coaching from standard 6 or standard 8, in turn skewing the competition landscape against most of the aspirants, meanwhile causing immense mental burden to the young students in coaching classes. With NEET - UG allowing multiple attempts, the percentage of repeaters gaining the medical seat is increasingly growing. As per the 2023 Tamil Nadu data on the eligible candidates for participating in the medical counselling process for selection in medical colleges, 69% of them are repeaters. In addition to the financial strain faced by candidates, the growing prevalence of repeaters in entrance exams reduces the chances of first-time candidates succeeding.12 FAILED PROMISES OF NATIONAL ELIGIBILITY CUM ENTRANCE TEST The NEET was introduced with the promises that the quality of the student entering medical college would be ensured, the issue of capitation fee would be tackled and the aspirants would not be burdened with multiple entrance tests. With the exception of the reality of NEET-UG being the sole qualifying examination for admission into MBBS/BDS courses in medical colleges across India since 2020 when All India Institute of Medical Sciences and Jawaharlal Institute of Post Graduate Medical Education and Research were included in the list of colleges for which NEET-UG score is valid, the arguments related to ensuring the quality of the student entering medical colleges, accessibility to and affordable quality medical education and the issue of capitation fee/high tuition free as much as 3,000,000 rupees per annum, have fallen flat. The qualifying percentile of NEET for Post Graduate13 and Super Speciality14 was slashed to zero percentile in 2023 by the National Medical Commission, under instructions from the Ministry of Health (Government of India), in the bid to fill the vacant seats. It is said that this practice of reducing the qualifying percentile to zero will not only allow private medical colleges to make money but also will lead to corruption and blocking of seats, wherein students with high merit might not be able to take the admissions while those with less scores and more money can. We are looking at the possibility of a similar circumstance for the NEET - UG, given the precedence set. Furthermore, in NEET - UG, the students are tested in Physics, Chemistry, Botany and Zoology, and the student who scores a single digit in Botany and Zoology can still qualify NEET - UG, by virtue of marks in other subjects. With regard to the question of fee regulation, the practice of collecting capitation fees has been replaced with the legally allowed practice of collecting sky-high tuition fees. Post 2023, the educational website Careers360 shared instances of students with abysmally low ranks, as low as 1,100,000, being able to secure medical seats (MBBS) by paying hefty tuition fees through the NRI quota route, as high as an annual fee of 7,200,000 Indian rupees.15 While the policy prescription for avoiding capitation fee payment in medical education lies in the realm of banking and income tax, the insistence of a legion of experts that a qualifying examination would solve it reflects poorly on the judgement of the policymakers and domain experts in our country. The National Testing Agency, which conducts NEET - UG, proclaims that its mission is to improve equity in education. This is in the face of the reality of NEET - UG as a sole examination for all the medical colleges in India, which can be attempted by Indian nationals, of Indian origin, overseas citizens of India, non-resident Indians and foreign nationals. It is unfortunate that a poor rural girl student from scheduled caste/other backward classes, studying in local language is forced to compete with an NRI student from United States of America, who is studying in a cream private school, taking expensive coaching classes, having the leisure of multiple attempts and who is prepared to take up the expensive NRI quota. The greater irony is both are judged by the same exam. NATIONAL ELIGIBILITY CUM ENTRANCE TEST - UG: LACK OF WILL TO OBSERVE The negative consequences of NEET - UG on the mainstream high school education system are telling, with the impacts widely reported in several places in Kota (Rajasthan), Telangana and Andhra Pradesh. The obsession with entrance examinations, fuelled by the troubling 'dummy school' system in Kota, sacrifices a quality school experience. This system allows students to enrol in a school, often paying full tuition, with the implicit understanding that attendance will not be a priority. This frees them to focus on rigorous preparation at coaching institutes. The cosy relationship between these coaching centres and dummy schools is no secret. With the proliferation of coaching institutes nationwide, the problematic Kota system of dummy schools is spreading to states like Punjab and Andhra Pradesh. The situation with NEET - UG 2018 topper Kalpana Kumari exemplifies this. While registered at YKJM College in Sheohar, Bihar, she reportedly prepared for NEET-UG as a regular student at Aakash Institute in Delhi. There is a wealth of data available over years regarding the socio-economic, caste and gender of the candidates entering the medical colleges and their performance after entering the medical colleges. But the sad fact is, the Union Government is unwilling to even consider these data to design the admission policy, and instead is forcing the single, centralized entrance exam on all the states. It is to be noted that NEET - UG was never intended to be forcefully implemented in states which did not provide assent to it when it was proposed. This kind of centralization doesn't allow the states to devise policies to align medical education with the specific public health requirements and socio-economic circumstances of the state. The policymaking institutions, including the legislature and the judiciary, should understand that the government medical colleges are an integral part of the public healthcare infrastructure of the state. Here, Tamil Nadu is clamouring for its Government Medical Colleges to be kept outside the NEET – UG-based selection mechanism for undergraduate student admissions and intends to use higher secondary exam marks as a sufficient test of merit, which has a low participation cost for the students. In a society where the class, caste and gender fault lines are very clear, insisting on high participation cost selection mechanisms is unimaginative policymaking, which skews the competition landscape, in turn preventing us from acknowledging the truly meritorious candidates. Furthermore, the farce of the 'supernumerary seat creation' policies in IITs to ensure women's representation needs to be unmasked, as the root cause for the poor women representation in IITs is due to the low percentage of women aspirants whose families have the will and means to enter the coaching class ecosystem, and the gender bias. Furthermore, as a practising medical professional, one knows that the quality of the medical professional cannot be pre-empted at the entry of the student into medical college but only on the exit. In the United States, where meticulous details about the correlation between the performance of the students in the entrance examination (MCAT) and the performance of the students in medical school are available, the studies indicate a weak correlation.16 'As can be the case with medical practice, admitting the right students to medical school is an inexact science'.17 'What began as a principle that seemed to offer an alternative to inequality has become instead a justification for inequality', says Michael Sandel, the author of the book, 'The Tyranny of Merit'. The state of Tamil Nadu introduced the entrance examination as an alternative to the interview system, a system which was vulnerable to personal biases and failings of the interview committee, and later scrapped the barriers (CET, Improvement Examination), acknowledging how the alternative became a justification for inequality. It is precisely the reason why the state wishes for the NEET - UG to go, while strongly feeling that the private medical colleges and deemed universities need regulation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.