Medical education is expensive.1 Its expense is ultimately paid for by governments and learners. Its growing cost has meant that in the UK an increasing percentage of costs is being placed on learners. However, this growing burden has a number of unwanted consequences. The potential debt burden can put some students off applying for medicine in the first place. At the other end of the process, graduate doctors burdened by debts can mean some moving into specialties in order to simply earn money to repay their debt. This can result in an oversupply of specialists that the population doesn’t really need. Physicians who are motivated by the need to earn money can end up contributing to the spiralling costs of health care.
Numerous attempts have been made to reform various aspects of the system and so to prevent this outcome. These have ranged to very low-interest loans to debt forgiveness schemes for graduates who enter specialties of great need (for example, general practice) to the development of low-cost formats of medical education.2,3
However, an alternative and more radical approach would be to ask whether medical education could be free in the first place. Would this be possible? The political context in the UK would make it seem almost impossible, yet it may be instructive to look outside of the UK.
We do not have to look far. In Germany higher education is free. There was an attempt in 2005 to introduce tuition fees but this was abandoned.4,5 Scholarships are also available to cover living expenses, books, and other necessary equipment. Similarly, in Norway there are no tuition fees and students can also receive grant funding. In France, the annual tuition fees for higher education are very low. If students cannot afford to pay these fees, scholarships are available. In Belgium, the cost of higher education is similarly low. The fees are means-tested but even those who aren’t eligible for financial assistance pay tuition fees of less than €1000.
There are other countries that do not charge tuition fees or that charge very low levels of fees. The purpose of this article is not to list all such countries. Rather, its purpose is merely to state that some countries can overcome their student debt problem by making higher education free. How do they do this? Simply by means of public funding made available through their taxation systems. Do they still have good healthcare systems? All four of these countries are ranked in the top 25 countries in the world according to the World Health Organization (WHO). According to the WHO, France has the best healthcare system; Norway is in 11th place; Belgium in 21st; and Germany in 25th, (the UK resides at number 18).6
So countries can still produce graduate doctors that can deliver a first class health service, without students being charged at all, or with them being charged minimal amounts. Despite all the ideological arguments that a paid-for product drives innovation and service, these countries are able to set aside ideology in this context.
The only question that remains is: why can’t we?
- © British Journal of General Practice 2015