K Srinath Reddy
Should medical education be governed through self-regulation by elected representatives of the profession? Or does the government have the responsibility to ensure that the mould for making doctors matches the requirements of the health system and meets the needs of the people? Should there be a facilitated crossover from non-allopathic systems to allopathic practice, to fill the gaps created by shortage or non-availability of allopathic doctors? In a federal system, should the central government have overwhelming power to constitute and control a regulatory body that oversees all aspects of medical education, leaving little role for the states? Will national entrance and exit examinations at the undergraduate level set quality standards in medical education or disadvantage some sections of students? Will incentives given to private medical colleges, through several relaxations, reduce the huge regional disparities in medical colleges or only give a free run to commercialisation of medical education?
These are among the many questions that are being hotly debated around the Bill proposing the replacement of the Medical Council of India (MCI) by a National Medical Commission (NMC). The Bill, which surfaced after several abortive attempts over the last decade to replace or reform the MCI, has now been referred to the Parliamentary Standing Committee for a review. Protests by the Indian Medical Association (IMA), and concerns expressed by many votaries of reform over infirmities in the Bill, weighed in to change the government’s intent to introduce the Bill for parliamentary passage in January.
While self-regulation is practised in other professions such as law, medical education is pivotally linked to the system which has to deliver a variety of health services to the people. The government has a responsibility to ensure that the system is adequately resourced with the needed categories, numbers and quality of health professionals and is accountable for the overall performance of the health care system. The manifest failure of self-regulation through the MCI is too evident to rely on it. However, a nominated body with a limited representation of elected professionals and scant representation of the states militates against participatory governance by marginalising key stakeholders. A third of the NMC should comprise elected professionals, with a genuinely representative electoral college, and regional representation must be provided. Among the nominated experts, public health is unrepresented despite the paramount importance accorded in the National Health Policy and Niti Aayog’s Action Plan. That needs correction.
The NMC will operate through four boards regulating undergraduate and post-graduate education, accreditation and rating, ethics and medical registration. For the huge mandate of the boards, having just three members in each is grossly inadequate. At least five members are needed. The NMC is to be “advised” by a 67-member Medical Advisory Council (MAC) which provides representation to states and Union Territories but is strangely packed with all 25 members of the NMC, with a common chairman. With a specified quorum of only 15, there is danger of the MAC becoming an echo chamber of the NMC.
Undergraduate education will be positioned between two gates: A National Eligibility-cum-Entrance Examination (NEET) at entry and a National Licentiate Examination (NLE) which controls the permission to practise and screens for selection to postgraduate courses. Countrywide variations in schooling may disadvantage students educated in regional languages with a curriculum that deviates from those of the central boards. Unless the NLE is carefully designed, there is the danger of a sizeable number of medical graduates who passed their university level examinations being barred from practice, when the country is short of doctors. While standardisation is highly desirable, the process must not become counterproductive and inequitable.
The most fiercely contested proposal in the Bill is a cross-learning platform that provides a “bridge” for cross-practice of allopathy by graduates of ayurveda and homoeopathy. Poor past planning in the production, placement and pay scales of allopathic doctors should not lead to the current expedience to push non-allopathic healers to abandon their training and wear allopathic masks. While mutually respectful cross-learning should be encouraged, forced marriages (“pakadua vivah”) are disrespectful to both streams of medicine and undermine our proud public proclamations on the strength of India’s traditional systems. Ayurveda and homoeopathy need to be promoted in their own right. Within the allopathic universe itself, there is a need to build pathways of inter-professional education between medicine, nursing and allied health professional training. How else will we produce nurse practitioners, nurse anaesthetists, physician assistants and many other boundary-spanning categories that contemporary health systems require? The NMC Bill ignores this.
The Bill also overreaches in assigning functions to the NMC, which is expected to “regulate” medical research and prepare a roadmap for “healthcare infrastructure”. While the former ignores the role of the Department of Health Research, Indian Council of Medical Research and many other agencies, the latter appears to take over the mandate of state and Central health ministries. It is audacious to conceive that the NMC has the capacity to map and mould the healthcare infrastructure of both public and private sectors for all of India, even as it addresses the onerous task of reforming and regulating medical education.
The concessions provided to the private sector have raised eyebrows, whether it is in the freedom to start new colleges without prior inspection, raise the number of seats or have fees fixed by the NMC in only “upto 40 per cent of seats”. While these are intended to incentivise investment in new medical colleges, it is doubtful that new private medical colleges will spring up in states which now have very few. The government has to invest in upgrading district hospitals in those states and link them to new medical colleges.
Despite the need to apply several correctives to the draft Bill, the creation of the NMC is a step forward in re-purposing medical education to fulfil societal expectations and not just professional aspirations. Transition from the MCI brings hope of greater transparency and accountability. The Standing Committee must tend to the Bill, to improve, not abandon it.