As a medical intern in an urban health centre in Gujarat, Kaushal recalls dealing with a six-year-old burn patient and a factory worker with a severed thumb the same night. His job at the state-run facility was to check their vitals, assess their injury, record observations, and treat—all on just a few hours of sleep. And no pay.

There were 20 other interns in the centre with Kaushal (who wanted to be addressed only by his first name for fear of repercussions), and none of them were paid by the state. Only because they all got their primary medical degree from outside India, and the system here wasn’t built to accommodate them.

It’s not that the country doesn’t want these doctors. It actually needs them—badly.

In a country of over 1.4 billion people, there are just about 1.4 millionPress Information BureauMeasures taken to increase medical professionals and improve their availability in rural areas registered “allopathic” doctors. That means one doctor for about 1,260 people—much lower than the 1:1,000 doctor-population ratio the World Health Organization (WHO) recommends. (The government claims the country has a better ratio of 1 doctor for 836 people, but it includes AyushAyush doctorsProfessionals who practice ayurveda, yoga and naturopathy, unani, siddha, and homoeopathy doctors, too, in the math.)

Getting a medical degree in India is hard. It’s expensive. It’s competitive. Over 2 million students take the entrance test every year, but just about 5% end up getting seats. So, it’s easier for people like Kaushal to seek cheaper education abroad.

Every year, about 25,000 students fly to countries such as Russia, Ukraine, China, Georgia, and Uzbekistan to pursue medical graduation, according to government estimates. But their hurdles begin once they complete the six-year course.

Back home, these foreign medical graduates need to deal with a screening test, in which only about three in 10 candidates qualify. Plus, regional medical councils take forever to register them as doctors. And if and when they manage to clear that, there’s a mandatory internship as well.

On its part, the National Medical Commission (NMC), which regulates medical education in India, has tried to make it easier for graduates like Kaushal to come into the fold.