The National Exit Test (NExT) extends to the exit point of medical education, the same centralising logic that unsettled its entrance. Section 15 of the National Medical Commission Act, 2019, creates a common final-year undergraduate medical exam for granting a licence to practise and enrol in the State or National Register. It requires graduates with foreign medical qualifications to clear it for the same purpose, and makes its score the basis for admission to broad-speciality post-graduate courses.
NExT thus makes one high-stakes examination perform four distinct functions: final-year theory assessment, licensure, foreign-degree equivalence and postgraduate ranking. The first one intrudes into the university domain, the second protects patients by ensuring safe minimum competence, assessing foreign graduates determines equivalence with Indian standards, and the last ranks qualified doctors for limited seats and preferred specialities. Their fusion is not reform, but regulatory overreach masquerading as efficiency.
Although Section 15 envisaged NExT becoming operational within three years, it remains unimplemented. The National Medical Commission (NMC) notified the NExT Regulations 2023, but later deferred the exam ‘till further directions’; NEET-PG and the Foreign Medical Graduate Examination therefore continue. This pause should be treated as an opportunity to correct NExT’s basic design flaw before it hardens into institutional practice.
Medical competence is not created by a single nationally controlled examination. It is formed over years in laboratories, dissection halls, outpatient departments, wards, emergency rooms, operation theatres, practical examinations and internship
The NExT Regulations 2023 prescribe a two-step model. Step 1 is a centrally administered, computer-based theory exam conducted by the NMC or an institution designated by it. It consists of six multiple-choice-question (MCQ) papers covering core clinical subjects, with integrated pre-clinical and para-clinical components. A candidate must secure at least 50% in each paper.
Step 1 replaces the conventional university theory exam of Final MBBS Part II. Entry into the mandatory 12-month internship therefore requires passing both NExT Step 1 and the university practical or clinical exam. The Step 1 score also determines postgraduate broad-speciality merit ranking, unless the candidate reappears, in which case the latest score prevails.
Step 2 comes after internship. It is conducted by the respective state health universities or authorised institutions, in accordance with NMC standards. It is an in-person practical, clinical and viva voce exam covering 7 clinical disciplines, assessed only on a pass/fail basis. Candidates must clear both steps within 10 years of joining the MBBS course.
NExT is difficult to reconcile with NEET-PG’s past record. Under NExT Step 1, a candidate must secure at least 50% in each paper. By contrast, NEET-PG’s initial General-category threshold (50th percentile) translated between 2021 and 2025 into only about 275-302 marks out of 800 (roughly 34-38%).
Even this modest benchmark was lowered during counselling: to the 35th percentile in 2021, 25th in 2022, zeroth in 2023, 5th in 2024 and 7th in 2025. This was done to fill vacancies, especially in high-fee private medical colleges and deemed universities. The OBC, SC and ST thresholds, initially fixed at the 40th percentile, were lowered still further.
A zeroth-percentile cut-off makes every otherwise eligible candidate who appeared for the exam eligible for counselling, including those with zero or even negative marks (up to minus 40). Such dilution may serve vacancy management, but it cannot be a public-safety standard for licensing doctors.
If NExT’s 50% floor is enforced, hundreds of PG seats may remain vacant; if diluted, licensure loses credibility. This contradiction may partly explain why NExT remains unimplemented.
Replacing the conventional university theory finals with a centralised MCQ examination is educationally unsound. MCQs may suit large-scale screening, uniform marking, and administrative convenience, but they are a poor substitute for long-form answers, case analysis, and differential diagnosis.
A final MBBS examination must test clinical reasoning: diagnosis, exclusion of alternatives, treatment choice, anticipated complications, safe prescriptions and uncertain evidence precisely what MCQs are least equipped to assess.
The problem is compounded by the fact that postgraduate admission depends solely on the Step 1 theory score, while Step 2, which is closest to actual medical practice, carries no ranking weight. That sends a dangerous signal.
Final-year students and interns will focus on the test that determines their PG speciality and institution. Bedside learning, case presentation, ward work, patient communication, supervised responsibility and internship-based clinical training will yield to coaching institutes, question banks and mock tests. Thus, an examination meant to strengthen clinical competence may weaken it.
A national ranking test can continue, but with an absolute, non-dilutable minimum standard, such as 50% in each paper. It should not be the sole determinant. It should be combined, on a 50:50 or similar basis, with statistically harmonised MBBS performance, structured clinical assessment and objective internship records
NExT also diminishes universities and teaching hospitals. By replacing conventional university theory finals with NExT Step 1, it intrudes into a core academic function.
Medical competence is not created by a single nationally controlled examination. It is formed over years in laboratories, dissection halls, outpatient departments, wards, emergency rooms, operation theatres, practical examinations and internship.
Universities and teaching hospitals are where this formation occurs. They must be held accountable for it, not reduced to instructional platforms for a centrally controlled theory test.
Uneven university standards should be addressed through an NMC-prescribed competency framework, structured practical/clinical examinations, external examiners, inspection, audit and public disclosure of institutional outcomes.
The federal imbalance is equally serious. States run medical universities, teaching hospitals, and public-health systems. They establish and finance most medical colleges, employ doctors, administer hospitals, spend over four-fifths of public health expenditure, and bear the consequences of poor outcomes.
The Union can prescribe minimum standards, but standards are not a warrant for assuming every function. To centralise entry through NEET, and exit, licensure and postgraduate ranking through NExT, is to accumulate authority without corresponding responsibility for healthcare delivery.
Comparative experience reinforces the objection to NExT. Mature federations such as the United States, Canada, Australia and Germany do not compress medical education, licensure, postgraduate selection and foreign-graduate equivalence into one national exam.
Universities or accredited medical schools retain responsibility for education and degree completion. Licensure is granted by State, provincial, territorial or Länder authorities, sometimes under national standards or after national qualifying tests. Specialist training is allocated through separate residency matches, specialty colleges, hospital appointments or decentralised selection processes.
Foreign medical graduates usually follow distinct equivalence pathways involving credential verification, knowledge testing, clinical assessment, language proficiency or supervised practice. The principle is institutional separation: public-safety licensing is kept distinct from competitive specialist selection. NExT would move India in the opposite direction.
India’s medical-education regulation rests on a striking contradiction. The Union government seeks ever tighter control over the formal system through the NMC, NEET and NExT, yet remains largely passive about informal healthcare providers, or ‘quacks’, who sustain primary care in rural areas and low-income urban settlements.
The Madhya Pradesh Cohort Study (2016) found that 77% of rural primary-care visits were to informal providers, against only 4% to MBBS doctors. Quacks were present in 99% of surveyed villages; MBBS doctors in only 30%.
The MAQARI Project (2016), covering Rajasthan, Madhya Pradesh, West Bengal and Uttarakhand, recorded 54-75% dependence on them. Slum studies (2010-15) in Delhi, Mumbai and Kolkata found 30-50% dependence. A 2016 WHO report found that 57.3% of those practising allopathy in India lacked formal medical qualifications, rising to nearly 80% in rural areas.
This is the more serious regulatory abdication. To obsessively standardise admission and exit exam, while leaving everyday primary care to informal and unregulated providers, is to mistake control for reform. India’s priority should be accessible, qualified and accountable public primary care — not more centralised filters for those already inside the formal medical system.
The remedy must begin by amending Section 15 to undo the fusion of four distinct functions. First, the final MBBS exam should remain with universities. Secondly, the university MBBS degree, followed by compulsory internship and registration with the State Medical Council or National Register, should remain the basis for the licence to practise. Next, foreign medical graduates should follow a separate equivalence pathway. And lastly, postgraduate admission should remain a distinct competitive process open only to licensed doctors.
A national ranking test can continue, but with an absolute, non-dilutable minimum standard, such as 50% in each paper. It should not be the sole determinant. It should be combined, on a 50:50 or similar basis, with statistically harmonised MBBS performance, structured clinical assessment and objective internship records.
Most importantly, unfilled private and deemed-university seats should revert to States for merit-cum-reservation allotment at government fee levels, preventing a system stringent for the poor and permissive for the rich.
NExT gives one test too much power, and gives hardly any respect to universities, states, patients, and medical education itself.
— The author is retired IAS officer of Tamil Nadu cadre, former Vice-Chancellor of Indian Maritime University, Chennai, and Member, High-Level Committee on Union-State Relations constituted by the Government of Tamil Nadu