Over the past decade, despite prolonged litigation, the National Eligibility-cum-Entrance Test (NEET-UG), the world’s largest single-stage pre-medical entrance examination, has replaced several state-wide pre-medical entrance examinations and different state-level syllabuses. It is mandatory to clear this examination to secure MBBS admissions in India.The primary aim of implementing NEET-UG was to create a more equitable and merit-based admission system by providing a single national entrance examination and reducing the burden of multiple state-level pre-medical entrance tests. However, its implementation has been highly contested by several states.Critics argue that recurrent administrative failures, allegations of irregularities, and concerns over fairness have undermined confidence in the examination and exacerbated tensions between the centralised admissions system and state-level educational structures. Given that each state has its own education system, with varying curricula, languages and implementation practices, the rationale for centralising medical admissions has become a subject of considerable debate.While NEET-UG was introduced to establish a uniform national standard and a merit-based selection process, critics question whether centralising admissions necessarily serves India’s national interest. Instead of ensuring equal opportunities, the growing reliance on a single high-stakes examination has seemingly transformed medical education into an intensely competitive process. It has shifted the focus of secondary education away from regular classroom learning towards intensive coaching-centre-led preparation.The number of students taking the NEET-UG entrance examination has surged from 7 lakhs in 2013 to 22 lakhs in 2026 and 50% of candidates meet the qualifying threshold every year. This does not mean all qualified candidates get medical admissions.Unavailability of medical seatsEven though the number of medical seats has increased from 51,000 in 2013 to 1,36,939 in 2026, about 54% of the medical seats (73,643 seats in total) are in private medical institutions. These seats are virtually impossible for middle-class and lower-middle-class students to access even if they secure a high rank in the examination.From 2013 to the present, there has been a consistent expansion of undergraduate medical seats, but more than half of the new seats were added in the private sector. In other words, 90% of the qualified candidates do not have a chance to secure medical admission due to the lack of capacity in government institutions. Exorbitant tuition fees at private institutions push thousands of Indian students to pursue medical education abroad as an alternative route to becoming doctors, despite the significant financial, regulatory and administrative costs involved.This places additional pressure on the limited number of publicly funded medical seats and has contributed to the proliferation of private coaching institutions, while the state rarely provides comparable preparation. This market-driven approach to merit has contributed to growing inequalities and further disadvantaged the socio-economically disadvantaged sections of society, who were already struggling to achieve professional advancement through education.Also read: Dreams and Paper Leaks Collide: Understanding India Through the Lens of NEET and UG-NET FiascoThe chances of gaining admission to premier medical institutions such as AIIMS are extremely low. With an acceptance rate of approximately 0.17%, even candidates scoring 95% or more of the passing mark in NEET-UG may fail to secure a seat in these highly competitive government medical colleges. The intense competition also affects students from reserved categories, including those belonging to the Economically Weaker Sections (EWS), as the number of qualified applicants far exceeds the seats available within each reservation category.At the same time, students from wealthier backgrounds may obtain admission to private medical colleges through management quota seats despite achieving substantially lower NEET-UG scores, provided they can afford the considerably higher tuition fees. This contrast highlights the persistent tension between merit-based selection and the role of financial resources in determining access to medical education.Although female students outnumber male students among the NEET-UG candidates, their representation among the top 50 rankers is quite low. It is disheartening that not a single female student from the Scheduled Caste or Scheduled Tribe communities appears among the toppers, and that the qualifying students are overwhelmingly from the general category.At the same time, since its inception, only five students from the Scheduled Caste category and three students from the Muslim minority community have ranked among the top 50, while no Scheduled Tribe student has done so.On the other hand, only 1.3% of qualified students were from the Northeastern states and none of them ranked among the top 50.An important question concerns the profile of the approximately 50% of NEET-UG candidates who fail to qualify each year. To what extent are these students disproportionately drawn from vernacular-medium schools, state-board curricula, rural areas and socio-economically disadvantaged backgrounds with limited access to private coaching? If so, NEET-UG may represent a particularly unfamiliar form of assessment for students whose schooling has not prepared them for highly competitive, coaching-oriented entrance examinations.Instead of providing all candidates with an equal starting point, the examination may instead reproduce pre-existing educational inequalities. In this sense, equality of opportunity should be understood not merely as granting access to the same examination, but as ensuring that students have comparable opportunities to prepare for and compete in it.Furthermore, the growing reliance on private coaching, together with recurring controversies surrounding examination irregularities – including reported paper leaks – has contributed to heightened stress and anxiety among aspirants. These pressures have been associated with student suicides and widespread public protests, raising concerns about the social and psychological costs of India’s highly competitive medical admissions system.Also read: When Competitors Became Citizens: The Exam, The Protest and The Work of DemocracyThese developments suggest that debates over NEET-UG should extend beyond questions of merit and standardisation to include issues of educational equity, student well-being and the structural conditions under which competition takes place.Is decentralisation an option?The centralisation of medical entrance examinations has had profound consequences for millions of students across India. A single national examination has effectively encouraged all students to prepare according to the CBSE curriculum framework, regardless of their educational background.As a result, families often spend substantial sums on long-term coaching programmes or integrated NEET-coaching in an attempt to bridge this gap. This raises a broader question about the changing nature of the country’s education system. Has formal schooling gradually been reduced to a qualifying requirement, while private coaching has become the primary mode of preparation for higher education?In many coaching institutes, students devote most of their time to NEET preparation from the first year of upper-secondary (Class 11) education, while regular school subjects receive attention only shortly before final examinations, primarily to secure passing grades. In practice, coaching has become the dominant educational pathway, relegating formal schooling to a secondary role. This model has shaped medical entrance preparation for decades.It is therefore worth asking whether a more decentralised admissions system – one that better reflects India’s diverse state education systems – could reduce dependence on shadow education, alleviate financial pressures on families and restore greater value to mainstream schooling.Is FMGE an alternative route to become a medical professional?Owing to intense competition for medical education, thousands of students pursue MBBS degrees abroad – including in other South Asian countries. Despite the scale of this migration, there are no comprehensive government statistics that provide the number of Indian students enrolled in medical programmes overseas. However, it is known that a total of 78,905 Indian students have earned medical degrees from 489 foreign medical institutions across 45 countries and subsequently returned.At the same time, Indian medical students studying abroad generally have even more limited access (than students in India) to scholarship schemes provided by state or central governments.This raises important policy questions about the extent to which the government should support its citizens who seek medical education abroad, particularly given that many do so because of the severe shortage of medical seats, especially in government medical colleges.The Foreign Medical Graduate Examination (FMGE) pass percentage fell from 18% in 2012 to 12% in 2026, raising questions about the preparedness of Indian medical graduates and systemic factors impacting the examination system as well as student performance. Due to the extremely low pass rates, students rely heavily on coaching institutions to prepare for and pass the examination.It is also observed that despite government recommendations, the Indian government is reluctant to implement a reservation policy for FMGE candidates similar to other exams such as UGC-NET. The FMGE is a qualifying examination for obtaining registration to undertake the compulsory internship required for medical practice in India and for subsequently becoming eligible for post-graduate medical entrance examinations.Moreover, securing employment without post-graduation in medicine is quite difficult. It has been reported that, despite qualifying in the FMGE, students in several states were not provided with internship opportunities for months, sometimes for one to two years. On the other hand, they were also not paid appropriately by the state medical councils when they did make it to internships. Some states insisted that the FMGEs go for two years’ internship even though the NMC specifies a one-year internship.Taken together, these developments raise broader questions about the role of foreign medical graduates within India’s healthcare system. While the FMGE is intended to ensure minimum standards of competence and patient safety, its consistently low pass rates, the growing dependence on private coaching, delays in internship allocation, and uneven implementation of National Medical Commission regulations across states suggest that the pathway from obtaining a foreign medical degree to practicing medicine remains highly uncertain.Instead of serving as a straightforward alternative route into the medical profession, overseas medical education often places students in a prolonged and precarious process of examinations, administrative barriers and inconsistent regulatory practices.As India continues to face shortages of medical professionals in many regions, these challenges raise important policy questions about how the state can balance quality assurance with fairness, transparency and the effective integration of qualified foreign medical graduates into the national medical workforce.Dr Rasipogula Vinod Kumar received his Ph.D. from the Center for the Study of Social Exclusion and Inclusive Policy, University of Hyderabad, Telangana, India. Professor Mette Ginnerskov-Dahlberg is a Senior Lecturer and Associate Professor at Department of Education, Uppsala University, Sweden.