As the UK government announces its plans for funding in higher education, Peter Cross looks at how medical students around the world are expected to pay for their education and how the cost impacts on them

Lynette Mason, a final year medical student in the United Kingdom comes from good working class stock, the very sector of society that the UK government claims it is keen to see in medicine. Lynette feels lucky and privileged. Her mum works in a post office and her dad drives a bus. Like former Labour leader Neil Kinnock, she is the first member of her family to go to university. But the way things are going, she may be the last.

Lynette expects to qualify owing a total of about £10 000 ($16 355; a15 081). Not a vast sum, you may think, but far greater than what she expected when she first went to Cambridge University. She was lucky; she was one of the last students to receive a full grant, and her preclinical course had long summer holidays during which she could work to earn money. That work included employment as a barmaid and as a silver service waitress. She was able to remain solvent for the first three years of medical training.

It couldn't last. Clinical curriculum commitments deprived her of any chance to balance her books. She is now on her sixth student loan, of around £7000, has an overdraft facility of £1600 and is "always floating around that level," and has just taken out a professional studies loan of £2500 to cover her elective in India. And she owes £350 on a credit card.

Long before learning that the government was offering golden hellos to lure doctors to general practice, Lynette had considered returning to Wales to work as a general practitioner. This remains her ambition, and, if she claims her bounty, she could pay off her student debt in one hit.

Outrage

So why is Lynette Mason angry? It is a sense of outrage that others from her background will not consider medicine. She reckons someone starting now can expect to owe three times what she does by the time they qualify. Lynette feels that if she returned to her old comprehensive and told students considering entering the profession that they can expect to qualify owing £30 000 she "would be laughed off the premises."

A recent article in Juice, the student supplement of the Daily Telegraph, confirms Lynette's feelings. The number of university applications from the lowest socioeconomic group has decreased by 10%. It is reasonable to postulate that this number must be higher for applications to medical schools, at which courses are long and demanding.

If the trend to make medical education increasingly expensive for individual students continues there is a real danger that more and more potentially good applicants will be deterred from applying. Means tested grants will be as stigmatising as taking free school meals and likely to be taken up by a cynical minority who know how to work the system rather than people who really need them.

So what?

Does it matter if this trend continues? It does if medical training becomes the exclusive preserve of the children of the rich. Recent news bulletins contain rumblings of threats and sanctions against higher education establishments which fail to attract students from poorer backgrounds.

Beyond the UK

The thoughts of medical students outside the United Kingdom make sobering reading. An American student who did not wish to be named gave an account of the debts that medical students incur in the United States. They are massive by British standards, yet student debt is not on the political agenda. As far as the American public is concerned, medical students qualify, earn huge salaries, and have little difficulty paying back what they owe. Public sympathy is reserved for students embarking on lower paid public service work like teaching. Medical students from poorer families keep their heads down and feel lucky to be on the course.

"Financial support for Portuguese medical students comes from their parents," says Tiago Villanueva. This is for a number of reasons. Government scholarships are only awarded to the least well off. Part time employment is almost impossible because working patterns are inflexible in Portugal. A supermarket cashier, for example, would be expected to work five or six hours for five days a week, which is impossible to fit around medical training. Every couple with children who are studying are given an amount money by social security, dependent on parental income. The lower the income, the greater the funding. In Tiago's case it is a15 (£10; $16) a month and an additional a55 because his dad works for the government.

Tiago went to Finland on an exchange scheme last year and was amazed to discover how easy it was for Finish students to get flexible part time work. Students can work two or three hours a day and have relative freedom to choose which days they worked. French medical students get paid during their clinical years and Belgian ones are paid to do on-call shifts. Finnish medical students are paid for both.

Using special talents

My next port of call was Egypt where I gained the thoughts of Ahmed Magdy and Bishoy Morris. Egypt has no student loan scheme, except country grants cashed by poor students once during the first year. These grants only cover tuition fees. Some medical students work while in college, but this is rare as they need qualifications and experience when applying for a job, typically as sales representatives. Ahmed suggests that students who are short of money should think about their abilities and talents: "Everyone has something special or unique that can be used in a job." He also feels that students could minimise their expenses by using college facilities where possible. Ahmed feels that most students are "spoon fed, depending on their families for a long time."

Bishoy Morris agrees that Egyptian students are financially dependent on their families until graduation. Bishoy has never worked, nor have any of his friends. This year, his fees were around £12: "Medical student fees are very small compared to in the UK." Medical education is mostly funded by the government. Books are quite cheap and photocopying textbooks is common. There is a two tier system: two private medical schools and government based universities. Bishoy thinks that private schools do not provide better teaching, rather they accept students with low grades. But this comes at a price of 15 000 Egyptian pounds per year (£2012; $3289; a3034).

Private institutions

"I studied in a private institution," says Muhammad Bangash from Pakistan. "The difference between good private and good public medical colleges is at times colossal and is mainly in terms of the funding they receive. The cost of education in the public is minimal, around £400-£500 annually. In private universities on the other hand, the fee for Pakistani citizens is around £3500-£4000. You only get student loan schemes in the private sector but there are scholarships in public and private sectors. Muhammad's college lends money with minimal interest which students pay back in monthly instalments two years after graduation. But these loans do not cover living expenses. Muhammad stresses that, in the developing world, medical training is still restricted to the upper and middle classes. In Pakistan, students rarely work and study at the same time.

"Money won't be a problem"

"In India the state government of different provinces runs the majority of medical colleges," reports Sanjit Bagchi who knows medical students who do not have enough money for a meal. "After admission a student pays almost nothing. £100 is more than enough to get you to undergraduate level and during postgraduate studies each student gets about £100 a month from the government. Indian banks have student loan schemes but a clever student from a poor family could apply for the government sponsored national scholarship." Sanjit earns money as a freelance journalist writing for the Telegraph, the Statesman and Hindustan Times. "If you have a passion and give it a professional touch, money won't be a problem."

Turning away from higher education

So if you have a passion, money won't be a problem? Maybe that's also true in the United Kingdom. The Department of Education recently publishesd a long awaited and widely leaked white paper on university funding. It seems clear that charging tuition fees of up to £3000 a year will go ahead. The money will be repayable after graduates start earning over £15 000 per year, and the government will ride out the unpopularity this will cause them. There will be efforts to encourage people from places like the Rhonda Valley, Wales, to enrol in higher education and some will. But you have to agree with Lynette Mason--many others will turn their backs on medicine and choose a shorter course in something else or forget about higher education altogether.