Foreign medical education: Widespread. Unknown. Unregulated

GLOBAL

Strange things are going on worldwide in the area of medical education and related fields, such as dental education and veterinary medicine.

On the one hand, there appears to be a shortage of medical doctors, while at the same time governments, and in many cases also medical doctors themselves, oppose increased access to the study of medicine. As a result, there has been an increase in international mobility of medical students from high-, mid- and low-income countries.

The education of medical doctors and specialists was once an international enterprise. Some of the first universities in the Western world, for example, the University of Bologna, established in 1088, educated medical doctors from all over Europe in Latin – the English of the day.

Later, medical education became largely a national endeavour, regulated and controlled by governments and medical authorities. But for a variety of reasons, medical education has, sotto voce, become internationalised. Because of national and global health needs, it is worth examining this particular global medical environment.

The fundamental fact is that an insufficient number of doctors (and of most other health professionals as well) are being trained to serve the populations in their countries – both in the growing populations of the Global South and in the ageing populations of the rich world.

The numbers of doctors are controlled by limiting enrolments in medical schools, and changing such policies encounters opposition from within the medical field itself, as demonstrated by recent strikes by medical doctors in South Korea opposing the government’s proposal to expand access to medical schools.

As a result, students look for alternative options abroad. No one knows how many international students are studying in medical schools outside their home countries, but a conservative estimate might be more than 200,000 – many of them in institutions and countries with a questionable quality of medical preparation.

To give an indication, Ukraine, before the Russian invasion, had 24,000 medical students from abroad, mainly, but not exclusively, from India.

Some interesting examples

India is an interesting example. The country has a severe shortage of doctors. The demand for places in medical colleges is considerable and, as a result, competition for places is huge.

Annually, 2.3 million students sit for the national medical school entry exam, but only one in 11 successful candidates are able to enter the country’s 707 medical colleges. As a result, 25,000 Indian medical students go abroad to study.

India’s Prime Minister Narendra Modi has promised that 75,000 additional places will be created in the coming years, but one can wonder if that is realistic.

In the past year, there have been several other interesting examples of dysfunction and internationalisation. Conflicts in several countries have revealed little known instances of medical education internationalisation.

At the start of Russia’s invasion of Ukraine, several thousand medical students from South Asia and Africa were evacuated. More recently, riots against (mainly) Pakistani medical students in Kyrgyzstan sparked evacuations, and protests in July 2024 in Bangladesh have led to the departure of many medical students from other South Asian countries across the Indian border.

These countries, and many others, provide medical education to international students, often in private medical schools of questionable quality, to earn income.

Offshore medical universities (OMU) are an important phenomenon in the Caribbean area, where they admit applicants who do not qualify for admission to United States or Canadian medical schools and who intend to return to these countries when they graduate. They also host a growing number of medical students from India, who have been rejected by the highly selective medical schools there.

There are now more than 60 OMUs in the Caribbean with perhaps 20,000 students, almost all of which are for-profit enterprises. For an overview of these offshore medical programmes in the Caribbean, see the valuable article by Stefan Trines in World Education News and Reviews.

Several countries – the Philippines is an important case – provide medical training for physicians and especially nurses for their own citizens, knowing that the large majority will leave the country for more lucrative careers in the United States, the Middle East and elsewhere. This provides remittances that are important for the local economy, but leaves the country with a shortage of medical personnel.

The curricula of these ‘export-oriented’ medical and nursing institutions are usually tailored to the requirements of the receiving countries.

The Philippines is not the only example of a ‘brain drain’ of medical doctors and nurses from the Global South. For example, 50% of doctors and 24% of nurses trained in Ghana are working outside the country. Likewise, 26% of physicians trained in Ethiopia work abroad. (One country, Zimbabwe, has made it a crime to recruit health workers to go abroad.)

The list goes on, and is by no means limited to Africa. This trend is bound to increase as rich countries face shortages of personnel and are happy to poach brains from wherever they might be found.

A broader trend

The above examples address the problematic phenomenon of students leaving the Global South, in particular South Asia and Africa, to study medicine in other mid-income countries.

But the trend is broader. For many years, students from Western countries such as France, Germany, the Netherlands and Norway, have been going to neighbouring countries for their medical studies, due to a lack of access at home.

Romania, where medical study is provided in French, Hungary and Poland are common host countries. The latter two countries also receive medical students from the United States. Thousands of US students study medicine in these two countries, as well as in Ireland and the United Kingdom.

Medical programmes in Central and Eastern Europe, as well as in Central Asia, cater for diaspora students and teach in English. The Medical University of Warsaw, for instance, has medical study programmes in both Polish and English. Currently, due to a lack of national funding for places at their home universities, about 3,000 Norwegian medical students receive scholarships to study abroad, mainly in Central and Eastern Europe.

An unregulated and largely unknown sector

In other words, the phenomenon of foreign medical education is widespread, almost completely unknown and unregulated. Where entire medical schools are devoted to international enrolments, they are almost exclusively for-profit institutions. Medical schools established in non-English speaking environments, such as Poland and Ukraine, offer English-medium medical curricula to attract high-fee-paying international students.

This industry seems to be composed of several different kinds of institutions. Some are independent, largely for-profit medical schools set up to educate students from abroad who go elsewhere when they finish their training.

Others are medical schools, largely private, that educate local students who will leave the country when they have completed their degrees.

Some are medical universities that, alongside their local curriculum, offer a curriculum, often in English (or, in the case of Romania, also in French), aimed at foreign students as a way of earning income.

Of course, established medical schools, public and private, also admit international students, but their numbers are relatively low and students are admitted mostly at the specialised levels. The United States, in absolute numbers the main host country for international students, hosts over 3,000 international students in health-related study programmes.

What’s the problem?

The ‘gold standard’ of medical education is training that combines traditional coursework, including some basic science, with guided ‘hands-on’ experience in a hospital or medical practice setting.

Few, if any, of the for-profit medical schools mentioned here provide such a model. Further, since many of the students involved in international medical education could not be admitted to their home medical schools because of low scores on admissions tests, in some cases the quality of the students themselves is questionable.

Little, if anything, is known about the faculty providing the education. And foreign graduates can seldom find internships in the best hospitals or universities. Even local students have problems getting access to internships at home, creating a demand for internships abroad that also meets quality control challenges.

Finally, while most countries require one or more additional exams for doctors who trained abroad, this measure is limited in scope – and many fail. For example, out of 35,819 individuals appearing for the Indian Foreign Medical Graduate Exam in 2024, only 7,233, or 20%, passed successfully.

As the examples of India and South Korea show, governments are starting to see the problem, but solutions are expensive and meet opposition from inside the medical establishment, which fears a deterioration of their privileges and elite status.

Yet, with rising ageing populations, the need for quality medical doctors will only increase. The growing number of students looking for medical education abroad illustrates a potential, but there is an overall lack of quality control. More attention is needed on this particular issue, on how to overcome challenges and safeguard the quality of the programmes.

Philip G Altbach is professor emeritus and distinguished fellow at the Center for International Higher Education (CIHE), Boston College, USA. E-mail: [email protected]. Hans de Wit is also professor emeritus and distinguished fellow at CIHE, Boston College. E-mail [email protected].

This article is a commentary. Commentary articles are the opinion of the authors and do not necessarily reflect the views of University World News.