Editorial 1: The problematic globalization of medical education

Context

The phenomenon of foreign medical education is widespread, almost completely unknown, and unregulated.

Introduction

Strange things are going on worldwide in the area of medical education. 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. While once medical education was international, now it is nationally regulated, but at the same time becoming internationalised. Because of national and global health needs, it is worth examining this particular global medical environment.

• No one knows how many international students are studying in medical schools outside their home countries,
  • But a conservative estimate might put the number to be more than 2,00,000 — many of them in institutions and countries with questionable quality of medical preparation.
• Ukraine, before the Russian invasion, had 24,000 medical students from abroad, mainly, but not exclusively, from India.

The India crisis

• 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 intense.
• Annually, approximately 2.3 million students sit for the national medical school entry examination.
• Only one in around 22 successful candidates is able to enter the country’s 700-plus medical colleges.

Growing Trend of Studying Medicine Abroad

• The fierce competition for medical seats in India has compelled many students to explore opportunities abroad.
• It is estimated that more than 20,000 Indian medical students go abroad to study.
• With limited government medical seats and high tuition fees in private institutions, studying medicine abroadhas emerged as an “affordable” and practical alternative for Indian aspirants.
• Countries such as Russia, pre-war Ukraine, Kazakhstan, the Philippines, China, Mauritius, and Nepal have become attractive destinations.

Indian-Controlled Medical Institutions Abroad

• Interestingly, some of the institutions in foreign countries are controlled by Indians.
• One such institution is the Manipal College of Medical Sciences in Nepal.
• It is the country’s first private medical college, which was established in 1994.
• It is operated by the Manipal Education and Medical Group (MEMG), Bengaluru.
• The American University of Antigua (AUA) College of Medicine, a Caribbean medical school, is also a division of Manipal.
• This reflects a broader strategy of Indian education groups expanding their footprint overseas to meet the growing demand from Indian students.

Challenges of Studying Medicine Abroad

• However, studying medicine abroad comes with its own challenges, particularly for those who wish to practise in India.
• Indian students who complete their programmes from foreign institutions must clear the national licensing examination to qualify for medical practice in India.
• They are also required to complete a medical internship upon their return.
• Similarly, Indians wishing to practise medicine abroad must satisfy licensing and other requirements of those countries.
• One can find Indian doctors throughout the world.
• This illustrates that governments are aware of the varying standards of medical education around the world.

Government Initiatives in Medical Education

• In a significant announcement during the Union Budget speech in February 2025, Finance Minister Nirmala Sitharaman highlighted the government’s achievements in medical education.
• She stated that the government had successfully added nearly 1.1 lakh undergraduate and postgraduate medical education seats over the past decade, an increase of 130%.
• She also revealed plans for further expansion in the medical education sector by announcing that an additional 10,000 seats would be introduced in medical colleges and hospitals in 2026.
• This initiative is part of a broader five-year goal to add 75,000 new seats, aimed at addressing the growing demand for qualified medical professionals.

Not just a Global South phenomenon

• The case of medical education in India illustrates the problematic phenomenon of students leaving the Global South, particularly South Asia and Africa, to study medicine in other mid-income countries.
• Many students often remain abroad after completing their studies.
• However, this trend is broader and not limited to the Global South.

Western Students Seeking Medical Education Abroad

• For many years, students from France, Germany, the Netherlands, and Norway have been going to neighbouring countries for medical studies due to limited access at home.
• Common host countries for these students include:
  • Romania, where medical education is available in French
  • Hungary
  • Poland
• Hungary and Poland also receive medical students from the United States.
• Thousands of U.S. students study medicine in:
  • Hungary
  • Poland
  • Ireland
  • The Caribbean
  • The United Kingdom

• Medical programmes in central and eastern Europe, as well as in Central Asia, cater to diaspora students and offer courses in English.
• The Medical University of Warsaw provides medical study programmes in both Polish and English.
• Due to lack of national funding for places at home universities, about 3,000 Norwegian medical students receive scholarships to study abroad, mainly in central and eastern Europe.

Unregulated Growth of Foreign Medical Education

• The phenomenon of foreign medical education is widespread, yet almost completely unknown and unregulated.
• Entire medical schools devoted to international enrolments are almost exclusively for-profit institutions.
• Medical schools established in non-English speaking countries, such as Poland and Ukraine, offer English-medium medical curricula to attract high-fee-paying international students.

Conclusion: Balancing demand and quality concerns

As the recent Budget speech shows, the government is 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 an aging population, 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 key challenge.

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Editorial 2: China’s dam project opens the floodgates of concern

Context

While the project aligns with China’s ambitious energy transition goals, it has serious implications for India, which cannot be understated

Introduction

The planned construction by China, of a massive hydroelectric dam on the lower section of the upper stream of the Yarlung Zangbo river in Tibet, has become a matter of concern for India due to its potential impact on the local environment and spillover, the flow of water downstream, and bilateral relations. Originating in Tibet, the Yarlung Zangbo is called the Brahmaputra after it reaches the Indian State of Assam where it meets its important tributaries. In India’s Arunachal Pradesh, it is called the Siang.

Brahmaputra and China’s Hydroelectric Project

• Brahmaputra’s Role in Everyday Life: The Brahmaputra is a part of the everyday life of millions of people from India’s northeastern States and Bangladesh.
• China’s Hydroelectric Strategy: China’s decision to plan a dam on the Yarlung Zangbo is a part of its broader strategy to transition from coal to renewable energy sources, particularly hydroelectric power.
  • As outlined in its 14th Five-Year Plan (2021–2025), China aims to reduce its reliance on fossil fuels and achieve carbon neutrality by 2060.
• Concerns About Large-Scale Hydroelectric Projects While this transition is commendable, the reliance on large-scale hydroelectric projects raises significant concerns.
  • While the dam project aligns with China’s ambitious energy transition goals, its serious implications for Indiacannot be understated.

The legal dimensions

• The construction of the dam raises critical legal issues under international water law.
• The United Nations Convention on the Law of the Non-Navigational Uses of International Watercourses (UN Watercourses Convention) 1997 emphasises the principles of equitable and reasonable utilisation, the obligation to prevent significant harm, and the duty to cooperate.
• These principles are essential in ensuring that shared water resources are managed sustainably and equitably.

China and India’s Legal Position

• However, China and India are not signatories to the UN Watercourses Convention.
• Nor do they adhere to a robust framework of domestic laws governing transboundary rivers.
• The official documents on water published by the Chinese government maintain that Beijing is a benevolent upper riparian that follows:
  • The principle of international cooperation
  • The principle of people orientation
  • The principle of sharing rights and obligations
  • The principle of equal emphasis on development and protection

China’s Approach and India’s Concerns

• However, many of China’s lower riparian states accuse it for using water as a ‘powerful tool’.
• India, which is one of the lower riparian states, depends on rivers that originate in Tibet for one-third of its river water supply.
• Due to the increasing securitisation of water and the rise of assertive military nationalism, a number of Indian political analysts say that China poses a serious water threat to India, making it vulnerable to unilateral actions.
• India has regularly expressed its concerns about the projects on the transboundary rivers.

Memoranda of Understanding (MoUs) and Cooperation Mechanisms

• The memoranda of understanding (MoUs) between India and China on the sharing of water data about the Sutlej and Brahmaputra rivers have expired now.
• With ties improving between the two countries, there is a possibility that the MoUs could also be renewed.
• There is an expert level mechanism (ELM) to deal with water-related matters that meets regularly.
• In the absence of a concrete agreement, the ELM’s role in managing water-related matters between India and China is significant.

Significant environmental concerns

• Seismic Threats: The proposed dam is being constructed in one of the world’s most seismically active regions.
  • The risk of earthquakes poses a significant threat to the stability of the structure, with the possibility of catastrophic consequences for both upstream and downstream areas.
  • For instance, the earthquake in Tibet in January 2025 led to the death of more than 120 people, while over 150 were injured.
• Environmental Impact: The construction of such a massive dam disrupts river ecosystems, alters sediment flow, and threatens biodiversity in the river basin region.
  • The potential environmental damage extends to the loss of habitats for aquatic and terrestrial species and increased riverbank erosion.
• Impact on Bangladesh: Such a dam would also have an impact on Bangladesh, where the Brahmaputra enters from India.
  • However, Bangladesh has not expressed serious concerns over the hydroproject.
  • The main reason is the growing divide between Dhaka and New Delhi ever since the fall of the Sheikh Hasina government in August 2024 and the level of ties Bangladesh has with China.

A ‘water alliance’ and hurdles

• Impact Beyond Bangladesh: But this is an issue that will not just affect Bangladesh.
  • Water-related activities in Tibet will affect the other lower riparian South Asian states such as Nepal, Bhutan, and Pakistan.
  • To deal with the situation, it is better to have a water negotiation plan for the region.
• Challenges in Regional Cooperation: However, given the political situation in South Asia, it is tough to imagine a water alliance between the countries receiving water from Tibet.
  • An absence of an active regional organisation halts South Asia from developing a collective strategy to manage transboundary rivers and conduct negotiations with the upper riparian country.
  • Bilateral ties between India and many of its neighbouring countries are not in good shape and see fluctuations frequently.
• Political Influence on Water Issues: The water issue between India and China cannot be de-linked from their day-to-day political relations because of the influence of politics on water-related decisions.

Conclusion

The recent India-China diplomatic engagements raise hopes for renewing lapsed MoUs and improving trust through information-sharing on Tibet-origin rivers. China has reiterated that the dam on the Yarlung Zangbo will not affect water flow to India. However, New Delhi has expressed its concerns. To clear any doubts or concerns that the lower riparian states might have, the ELM would be a better platform.