India’s Foreign Medical Graduates: Long journeys Uncertain Destinations
A Conversation between Mr. Mevai Shanmuga Raja (MSR), Dr Haritha Sri Baskar Jayanthi
and Dr. T Sundararaman.
Several critical and long-standing issues plague Foreign Medical Graduates (FMGs) in India, affecting their careers and mental health. Many Indian students study medicine abroad due to high costs and intense competition for seats in India. Upon their return, however, they face significant hurdles, including discriminatory treatment, a difficult licensure exam, and a shortage of internship placements.
In this conversation we have invited one student and one parent to give us an insight into the motivations, experiences and challenges that foreign medical graduate face and we reflect on the implications of these for peoples health, as also the professionals themselves.
Mr Mevai Shanmugha Raja, is a post-graduate and a social and political worker. His insights come from the fact that all three of his children have graduated from foreign medical colleges- the eldest from China, and one from Phillipines and the third is now studying in Georgia. He has often had to appeal to the National Medical Commission and the courts in pursuit of a fair deal for these students. Through his personal experiences and extensive research, he has become a guide for many FMGs
Dr. Haritha Sri, a graduate from Vladivostok in Russia, has topped not only in her class, but in her licensing exams in India too. This amazing young woman is confident and optimistic that despite the incredible odds, she will create a purposeful and a successful career.
TS: Could we start with a broad description of what constitutes FMGs, and the scale of the issue and the drivers for so many students to seek medical education abroad at such costs?
MSR: The demand for medical education in India is very high. There are over 23 lakh students taking the National Eligibility cum Entrance Test (NEET) exams each year, for about one lakh seats that are available in India. Of these seats most are in the private sector- where the charges are exorbitant. The cost is therefore the main driver to go abroad. There are on an average 25,000 students joining a medical course abroad every year. The countries they go to are wide ranging- the main nations being China, Philippines, Russia, Ukraine, Georgia, Bangladesh. Students also go to Nepal, Mauritius and Timor Leste. A relatively smaller number of students go to the high-income countries of Australia, Canada, USA and UK.
Haritha: Apart from the previously mentioned locations, there are also students studying in Vietnam and Kyrgyzstan. I also have a few of my friends studying in Singapore and Malaysia as well. I completed my medical school in Vladivostok, the port city in Russia’s Far East. The city has several medical universities where many Indian students study. There are about three such universities in Vladivostok, and I studied at one of them.
TS: Other than this fascination for becoming doctors, what other factors could you mention?
MSR: Many students feel there are better education and career opportunities, especially if they have to migrate. Personal and family preferences also play a role. Often, it is a lack of awareness of the challenges ahead.
TS: What are the selection systems for students to enter a foreign medical course. How do students, or their families select where to study?
Haritha: After completing my 12th grade, I took and passed the NEET exam, but my score wasn’t high enough for a good government medical college, and private colleges were too expensive. Around that time, I saw an advertisement from the Russian Embassy about a promotional meeting, so my parents and I attended it just to explore the options. They showed us a couple of Russian medical universities and programs during the session. After the meeting, I spoke to a couple of students already studying abroad and did a lot of research on university websites with prepared questions based on what they said. I narrowed it down to two schools Kursk and The Far Eastern Federal University in the Vladivostok—I chose the latter because they offered a full academic six-year English program and had dorms that felt much safer and more convenient for girls instead of renting an apartment off-campus. The application process was straightforward. They checked my school certificates and my English language proficiency, and I also took an entrance exam, in Chennai by the Russian agency. It felt more like a basic screening than a difficult selection test. After I arrived in Russia, we were required to do an English language proficiency exam, and those who didn’t pass would have to attend extra English classes, but I cleared it.
MSR: Students must meet specific eligibility criteria of the country where they are enrolling. There is often an examination conducted in India. The courses can be varied. In Russia it is a six-year course. No separate internship In Phillipines there is a four- and half-year medical course preceded by a one0year pre-medical course. A one-year internship is mandatory. Not everyone passes the pre-medical, and if they do not, the student is stuck. It may take them more years to pass and then complete the course. There are pressures from litigation in Indian courts that aim to disqualify some of these courses. Many of the court cases against foreign qualifications are by proxies of Indian private hospitals who find this competition unwelcome. Indian government policy could also lean towards the interests of profit-making private medical education in India.
Before the NMC used to provide some guidance regarding which colleges abroad meet the required qualifications. But now they have stopped doing so. So sometimes students find that the course they have completed is not recognised in India.
Earlier, students went abroad, because they did not need to pass NEET. Now, since 2020, NEET is mandatory for students going abroad if they have to come back and get registration. Some students feel that the NEET exam requirement for studying abroad is unfair and view it as a “political war”. For going abroad, you need to pass NEET, but for a private medical college in India the bar can be relaxed to almost zero marks. Many students have proceeded abroad without clearing NEET or registering with the NMC, often because they are unaware of this rule-change, and this can create issues when they return to India and attempt to register and practice medicine.
TS: Can you provide a sense of the price of medical education abroad? Is there any regulation? Can they recoup these costs?
MSR: The cost of medical education abroad varies greatly depending on the country, university and program. I would say it ranges from Rs 35 to 45 lacs, including education fees, local food and accommodation, travel tickets, visa and agent commissions. This is less than the 80 lakhs to 1.5 crores that private medical education costs in India. I think it is easier to recoup the costs of FME as compared to Indian private medical education. And FMG allows you the option of finding career options in other countries. However, I think most graduates seek to return.
Haritha: Before applying abroad, I explored a few private medical colleges in Tamil Nadu. However, the fees were around 20 lakhs per year—about 1.25 crores in total, just for education alone. Students from well-established families or those with doctor parents who own nursing homes might be able to afford that. Well, I’m the first doctor in my whole generation coming from a normal middle-class background. Paying such a large amount was simply not possible for us. I didn’t want to give up on my dream, especially knowing what it could mean for my family and future generations, so we decided to consider studying abroad instead. My tuition fees came to about 1.2 lakhs per year, and food and accommodation for six years cost roughly 2.4 lakhs per year. Due to COVID restrictions and the war, I was able to travel back to India only twice during summer holidays, and I stayed in Russia continuously for four years. Altogether, I estimate that the total cost over six years was around 25 lakhs.
TS: When FMGs return – what problems do they face to start practice or secure employment here?
MSR: There are three requirements to fulfil, and each is a huge hurdle – clearing the FMG examination, then registration which includes doing a 1 year internship and then securing employment.
For getting a license to practice medicine in India, FMGs need to clear the Foreign Medical Graduate Examination. There is a Rs 12,000 fee to write this examination. This is held twice a year by NMC. The exam has a high failure rate, and therefore is the biggest barrier. On an average only about 15 % of students pass it. The pass rate varies across countries. Here are some indicative numbers: Bangladesh 26%, Philippines 24%, Russia 24%, Ukraine 21%, Nepal 19%, Belarus 19%, China 15%, Mauritius 15% Armenia 11%, Mauritius 15%. This is for year 2024.
FMGs from the 5 high income countries Australia, Canada, New Zealand, UK and USA are exempt from writing the FMGE- licensing examination. Their process of absorption is easier if they choose to stay, but most are seeking employment abroad.
After they have passed this licensing examination, FMGs have to undergo a registration process. The first part of this is to submit a number of documents that approve that the course undertaken meets the NMC criteria. And there are registration fees. Then with NMCs approval, the FMGs must undertake a compulsory internship or residency program. This residency is not easy to secure. Some medical college hospitals especially in the private sector could charge as much as Rs 6 lakhs for this. In Tamil Nadu state government hospitals in three districts are earmarked for returning graduates and these charge Rs 3 lakhs per year. In other districts, the government medical college charges could be higher, as much as 6 lakhs. Private medical college hospitals could charge even higher. Once they complete their internship they can register with NMC, and sit for post-graduation examinations or go into practice.
Even after clearing this, employment is a challenge. FMGs face stiff competition from Indian medical graduates, and they are vulnerable because many employers either do not recognize foreign medical degrees or have a bias against FMGs. This is reflected in that the FMGE is a tough examination and pass marks are over 50 percent, compared to much less requirement for entry into PG courses in India.
There is a stigma attached to the FMG and this creates social challenges: People may perceive FMGs as having inferior medical education or skills compared to Indian medical graduates.
There are also objective challenges in adjusting to the Indian healthcare system, culture, and social norms. They need to rebuild their professional networks in India, which can be time-consuming and challenging, with multiple requirements and exams to clear.
Overall, FMGs face a range of challenges when they return to India, and addressing these challenges will require a comprehensive approach that includes regulatory reforms, education, and support systems.
Haritha: I would like to highlight the significant time delays involved. As soon as I returned to India, I submitted my online application to sit for the FMGE. I had to wait six months for the exam and another two weeks for the results. After that, I applied for the NOC and Provisional Registration Number from the Tamil Nadu Medical Council (the state equivalent of the NMC). This process took another six months, followed by an additional three-month wait before I finally received my internship posting. By this time, I had already spent around ₹40,000. For the internship, we were given two options: pay ₹2 lakhs upfront and then receive a stipend of about ₹20,000 per month, or choose an unpaid option that provides a stipend of around ₹10,000 per month. Naturally, I chose the second option. In my understanding the demand for ₹6 lakhs or more for internships generally comes from private medical colleges and not from government medical college hospitals. Securing internship postings in government colleges can take a very long time, sometimes up to two years, so many students have no choice but to pay for internships in private institutions. This situation varies across states. Overall, including the internship process, it can take at least three years after returning to India before we can begin working, all while carrying a large education loan and without a stable income.
TS: But what is the experience with knowledge and skills gaps? Is there a real problem?
MSR: Quality of education across countries is very varied. The World Health Organization (WHO) also recognizes medical universities worldwide, and many countries have their own accreditation bodies and there are also international standards, guidelines and accreditation. Performance indicators such as student satisfaction, clinical skills, and knowledge acquisition, to assess the effectiveness of their training programs. Despite all this in many countries due to commercialisation, there is a lack of resources including libraries, qualified lecturers and not much exposure to seeing patients. It is private agencies that provide the guidance and their preferences could be influenced by their profits.
But there are other problems. There is a period of adjustment even in clinical tasks as they need to adapt to different clinical practices and protocols in India. There are differences in disease prevalence between India and their country of study. There is limited exposure to infectious diseases. Many countries where FMGs study have low incidence rates of diseases such as Tuberculosis (TB), Malaria, Dengue, and Typhoid. The curriculum in some foreign medical colleges may not emphasize preventive medicine and community health, which are essential components for clearing the licensing examination as well as for medical practice in India. These gaps in knowledge and training can make it challenging for FMGs to adapt to the Indian healthcare system and provide quality care to patients.
Haritha: Regarding the question about knowledge and skills gaps between FMGs and Indian medical graduates, I honestly don’t think there is a real problem. In Russia, the medical course is six and a half years long, which is actually more than what is required in India. We trained mainly in public hospitals, Private practice does exist, but it has not developed much, and our professors did very little of it. Our schedule included both hospital postings and regular lecture sessions, so the balance between theory and practice was good.
When I compare my experience with what students in India and other countries receive, I feel the quality of training I had was good. On top of that, we were encouraged to volunteer and participate in different medical activities. I completed more than 1,000 hours of volunteering, —this included working as a teaching assistant for junior batches, worked as a medical instructor for basics of first aid and educated more than 200 students and providing medical support at sporting events like cricket, football, and boxing.
Studying abroad also gave us exposure in areas that many Indian students don’t usually get. We interacted with students from different countries, learned to adapt to new systems, and became comfortable working in multicultural teams. We were also introduced to different styles of teaching, electronic medical records, and newer diagnostic platforms. Living on our own in another country also taught us independence, communication skills, and problem-solving—skills that are very useful in the medical field. So overall, I would say FMGs are not lacking in knowledge or skills. The challenges we face mostly come from the procedures and requirements after returning to India, not from the training we received abroad.
TS: What then explains the stigma against FMGs here? To what level is stigma a problem?
Haritha: Stigma and discrimination against FMGs are widespread. We are constantly compared unfavourably to Indian medical graduates, often without any real assessment of our abilities. For instance, a friend of mine was not even allowed inside the medical wards of a state government medical college simply because, as an FMG, he was assumed to “not know anything.” He was made to wait outside for three days, and even when he was finally permitted to enter, he was not allowed to perform the same duties as others—even though he had completed all the required formalities. This was deeply discriminatory. I have been somewhat more fortunate. The medical college where I am posted has only recently started, so there are no local interns—only FMGs. Still, even here, there is a common perception that FMGs are wealthy but incompetent. Both assumptions are completely untrue. Most of us come from middle-class families, many are in debt, and we are well-trained and capable. The truth is that the system is under pressure. With limited opportunities, long waiting periods, and uncertainty about the future, everyone is struggling. In such an environment, it becomes easy to blame FMGs for larger systemic issues.
TS: Given the enormous problems of being able to qualify for practice in India, would many choose not to return? Is that a possibility? What happens to the 80+% who do not pass the FMGE?
MSR: The possibility of not returning to India after studying medicine abroad is a viable option for only some of the students. While most Indian students pursue medical education abroad with the intention of returning to India to practice, some may choose to stay abroad due to various reasons like better career opportunities, challenges in clearing FMGE and if they have found a better quality of life. Many of the Russian and Central Asian countries are willing to provide jobs. Global Mobility, completing a degree in one country and working in another is possible by writing the relevant entrance exams of that country, and this can be done without requiring permission from the National Medical Commission (NMC). But most students seek to come back and they need employment here.
Haritha: I was part of a class of about 120 Indian students, and every one of us chose to come back initially. However, almost all of them are now trying to go abroad again—either for postgraduate studies or simply for better employment opportunities. For postgraduate training, the six major high-income countries are usually preferred because their qualifications are widely recognised and the medium of instruction is English. I consider myself fortunate because I am completing my internship in the third year of my return and am now applying abroad for my postgraduate studies. Most of my friends who have passed the exam are working in hospitals or nursing homes, earning around ₹30,000 to ₹40,000 per month. No one is in private practice yet, because it is simply not possible without full registration. A significant number of FMGs are not working at all—they are preparing for exams, waiting for internship slots, or searching for opportunities. Many are hopeful, but the uncertainty is high. For those unable to clear the FMGE, the options become even more limited: they either attempt the exam repeatedly, seek jobs abroad in non-clinical roles, or look for healthcare-adjacent work like health insurance companies within India. Overall, the system leaves many FMGs in a long period of instability, which pushes many to consider leaving India again—not because they want to, but because it offers a clearer and more predictable career path.
TS: If we count these unemployed graduates along with the graduates from private medical colleges within India, who face similar or more intense problems, it is a horrifying situation. A recent set of news articles have highlighted unemployment and under-employment amongst medical graduates. This includes many of them working as gig workers to repay loans, while hiding this from their parents and pretending to be practicing as doctors. Are there organisations of FMGs that try to help?
MSR: Yes, numerous organizations exist to help FMGs. These include International Medical Graduates Association (IMGA), All FMGs association (AFA), Indian Medical Association (IMA), Medical students’ association of India (MSAI).
Haritha: I am part of informal WhatsApp or Telegram social media groups. We share updates about exams, documents, or internship openings. There’s no official association yet, nor a political consciousness.
TS: What is the National Medical Commission policy on FMGs? What is your suggestions on these.
MSR: The National Medical Commission has a policy approach for Foreign Medical Graduates seeking registration in India. This policy specifies the eligibility criteria, the registration process and the internship requirements, as discussed earlier. The eligibility Criteria are English proficiency, proof of having completed 54 months of medical education plus 12 months of Internship from a recognized foreign university, and ensuring Indian standards quality by clearing the FMGE which assesses their medical knowledge, clinical skills, and understanding of Indian medical practices. Then a registration process involves submitting relevant documents, including the FMGE pass certificate, academic transcripts, one year internship completion certificate, and identity proof.
I think NMC could help by simplifying and streamlining the registration requirements with clear guidelines for internship duration, structure, and assessment to ensure consistency across hospitals and states. There is a need to expand the list of NMC-approved hospitals for internships and ensure that FMGs receive equal stipends and working conditions as Indian medical graduates during internships. The FMGE examination too should be more competency based and more transparent- we do not even have the questions they ask in past examinations. There is also a need to addressing the growing litigation challenges, largely driven by private medical colleges. This requires responding to Supreme Court directives and ensuring that policies are aligned with judicial expectations. Finally it would be useful to engage with parents and FMGs and public health officials too as stakeholders to develop effective and inclusive policies.
Haritha: I would agree with the above suggestions. There should be a centralized online system for internship allocation, faster verification of documents, and clear timelines. Also, awareness and notification about recognized universities should be increased so students can make informed decisions before going abroad. I am interested in learning more on this areas and research on these questions. Look forward to an opportunity to work with you.
TS: I think this conversation brings out clearly the huge numbers of Indian middle class students who are going abroad to get a medical qualification over the last two decades, and the tremendous struggle they face in finding the right college. in completing their studies, in registration on returning and in finding employment. Though eligibility thresholds and competence are probably higher for these graduates as compared to India’s mushrooming private medical colleges, policy and courts can be skewed to favouring the latter. Though portrayed as wealthy and privileged, in reality they are facing stigma, discrimination and unemployment. Much of this is a consequence of market-driven expansion of medical education whose aim was to generate profits in the professional education sector, while generating a large reserve army of unemployed or under-employed doctors which favours the growth of a highly profitable corporate private sector in healthcare. Yet many of these FMGs are motivated and competent and there is scope to organize them and shape policy to use them to strengthen India’s public health system.
This is the 26th conversation of a series of conversations on health policy published by RTH Resource Collective. All conversations can be accessed at https://rthresources.in/
Readers can also access other resources related to different aspects of health systems strengthening in this website.
About the Participants:
Dr Haritha Sri Baskar Jayanthi, is a medical graduate from Federal Far University in Vladivostok in Russia. She joined in 2017 and completed her studies in 2023. She has since passed FMGE and completed her internship and has been registered for practice. She is now preparing for postgraduate entrance examinations in India and abroad.
Mr Mevai Shanmugha Raja, is a post-graduate and a social and political worker. He is in activist in this area of work, and led appeals to the National Medical Commission and the courts in pursuit of a fair deal for these students. Through his personal experiences and extensive research, he has become a guide for many FMGs
