Sinking in Bureaucracy

The National Commission Bill, 2017, is being protested against for the proposed bridge course and bringing medical education under the clutches of bureaucracy

BY RITA DUTTA

The Indian medical education sys-tem has been plagued by charges of corruption and unethical practices that have flourished unabated.

To that effect, the National Medical Com-mission Bill, 2017, which was introduced by Minister of Health and Family Welfare, JP Nadda, in Lok Sabha on December 29, 2017, had proposed a sweeping overhaul of medi-cal education. However, met with vociferous protests, the Bill has been referred by the Lok Sabha to a Parliamentary Standing Com-mittee for a re-look.

The Bill is primarily based on the 92nd report of the Parliamentary Standing Com-mittee on Health that was submitted to the Parliament on March 8, 2016. As per the authors of the NMC Bill, a committee headed by ex-vice chairman of Niti Aayog, Arvind Panagari, there is a wide gulf in availability of qualified doctors, specialists, and super specialists, and a huge geographical mal-distribution of medical colleges under which two/three medical colleges are in the regions representing one third of the population. According to Panagari, now Professor of Eco-nomics at Columbia University, the report has listed numerous failures of the cur-rent Medical Council of India (MCI), which included “the failure to maintain uniform standards of medical education, devaluation of merit in admissions and failure to create any summative evaluation of medical graduates and post-graduates.” It also highlighted the failure to put in place a robust quality assurance mechanism and gave undue focus on infrastructure and human staffing of medical colleges.

Accordingly, the government of India came up with the draft NMC Bill, 2017, which proposed to repeal the Indian Medi-cal Council Act, 1956 and dissolve the MCI. Formed under the 1956 Act, MCI was set to establish uniform standards of higher educa-tion qualifications in medicine and regulat-ing its practice. As per the Bill, the NMC will function in sharp contrast to the MCI, which looks into a gamut of activities- from inspecting medical colleges to action against errant doctors.

The Standing Committee report is broadly based on the report of an expert commit-tee led by late Prof Ranjit Roy Chaudhury. As per the Roy Chaudhury committee’s recommendations, the NMC ill proposes a commission at the apex assisted by four autonomous boards, one each to oversee undergraduate education, post-graduate education, accreditation and ethics and registration.

But unlike the Roy Choudhury commit-tee report, which had recommended fewer members of the commission and no elected members, the NMC Bill proposes 25 mem-bers, a majority of them medical doctors and five of the latter to be elected by and from amongst registered medical practitioners. The commission includes non-doctors like patient-rights advocates and ethicists, in line with the medical regulators of the UK, Australia and Canada.

According to an article by Panagari, “To put an end to the tyranny of inspections, which focus microscopically on infrastruc-ture and personnel and threaten closure of institutions on the pretext of the slightest deviation from the prescribed norm, the NMC Bill proposes to replace them by an ac-creditation system and an exit examination.”

The Bill has been hailed for suggesting reforms in the medical education that would have a long-term impact on healthcare delivery. Says Bhavdeep Singh, CEO, Fortis Healthcare Limited, “The Bill has the potential to be a game changer in transform-ing the healthcare landscape in India. On the positive front, the Bill proposes to make NMC act as an apex body to bring in trans-parency and inclusive governance around medical education and practice in India. It also seeks to make clinical practice more standardised and uniform.”

However, various sections of the industry have been vehemently protesting against certain sections of the Bill. The Indian Me-dial Association (IMA) has termed the Bill “undemocratic”, alleging that the functioning of the medical profession would now come under the clutches of bureaucracy.

Key areas of concern in the NMC Bill:

  1. The bridge course:

To meet acute shortage of doctors, the NMC Bill has proposed a bridge course to enable alternative practitioners to turn over to Allopathy. Clause 49 of the Bill mentions a joint sitting of the NMC, the Central Council of Homoeopathy and the Central Council of Indian Medicine “to enhance the interface between homoe-opathy, Indian Systems of Medicine and modern systems of medicine”. Says Dr Alexander Thomas, President, Association of Healthcare Providers of India (AHPI), “The founding principles of modern medicine are evidence-based and are rooted in standard treatment protocols, which have nothing in common with the traditional systems of medicine. Therefore, mixing up of these systems of medicine through bridge courses will in no way be appropriate. On the contrary, it will undermine the patient safety and pave the way for promoting quackery.”

The cross learning would also impact medical education, lament experts. “And those who do not get admission at qual-ity institutes, will most likely take up a traditional medicine course, opt for the bridge course and cross over to modern medicine. Is that something we want to encourage,” asks Bhavdeep.

  1. NMC’s selected members:

To address the pitfalls of the electoral process, the Bill has suggested the central government to select most of the com-mission’s members. The major representa-tion in the committee comprises people selected either by the government or from the government.

The authors of the NMC Bill argue that the electoral process through which MCI members were picked was fundamentally flawed, because conscientious doctors avoid such elections. Because there was no ceiling on re-elections, the same group of members have monopolised MCI for years. To corroborate its point, the Standing Committee has questioned the appoint-ment of Dr Ketan Desai, who was elected MCI president in 2008, even though he had been prosecuted in the Delhi High Court for misuse of power as President in 2001.

The IMA has been up in arms against the government selection of NMC members and the fact that the representation in NMC for elected medical professionals is limited to just five members. If there are almost 8 lakhs doctors in India, why NMC will have just five elected representatives from the medical profession, IMA has sought to know.

Says Dr KK Aggarwal, Immediate Past President, IMA, “The nominated model of the regulatory authority has been experi-mented by the government of India in 2010 itself and it has failed. The regulatory authority stands reduced down to a group of handpicked nominated people by the central government, ending up becom-ing a government-controlled department rather than an autonomous regulatory authority.” He contended that in the year 2001, the Delhi High Court had appointed a full time administrator who supervised the functioning of the MCI for one year until he was replaced by a four-member monitoring committee appointed by the Supreme Court in the year 2002. “In the entire year, the full time administrator did not and could not bring even a single event pertaining to the functioning of the council, which could be said to be contrary to the governing rules and regulations,” points out Dr Aggarwal.

Echoes Dr BS Ajaikumar, Chairman, HCG, “An autonomous and independent body governing licensing, standardisation, accreditation, governance and monitor-ing of medical education is the need of the hour. The Government should restrict itself to an advisory role and not become a decision-making body or a pseudo decision-making body with major repre-sentation of the Government.”

  1. National licensiate exam:

The Bill has suggested a national licensiate exam to test the quality of the graduating MBBS students. This is meant to eliminate corruption in medical education and also to test the quality of the medical gradu-ates like the UK, Japan, Canada and many other countries do. However, the proposal was made at a time when the government had not introduced the common medical entrance exam for all colleges – the NEET (national eligibility cum entrance exam).

“Following the successful completion of the MBBS examination enforcing another licentiate examination is superfluous.

However, those aspiring to do post-grad-uate courses can be made to appear for common PG-entrance examination,” says Dr Alexander.

Adds Dr Arvind Kasargod, Director of Medical Services, Cloudnine Group of Hos-pitals, “The NMC Bill needs to monitor the quality of the education being imparted and the enforcement of the laws against the colleges and doctors who violate the written law of the country. Instead of penalising the people involved or improv-ing the medical education system, we have decided to penalise the students. That is unfair, as students have to study hard to get into medical schools and then work harder to pass multiple exams during their course in the hope of practicing medicine with what they were taught in Govern-ment recognised colleges and hospitals.”

With the Parliamentary Standing Com-mittee re-assessing the Bill, experts opine that the Committee is likely to recom-mend to the government to consider testing the MBBS students while they are studying medicine rather after they have graduated.

According to Bhavdeep, the current sys-tem has an over dependence on doctors and less emphasis is laid on training, experi-ence of allied areas such as nursing and com-munity health. “This is an area which needs to be urgently addressed,” says he. Whether integrating all the streams of medicine is a possibility to meet dearth of doctors needs to be debated on, before it is discarded. To address shortage of doctors in rural areas, Dr Arvind suggests training of mid-level prac-titioners like physician assistants and nurse practitioners. “The training should mainly be in outpatient and preventive medicine and after completion, they should be licensed to work,” says he.

Now that the government is working on fine-tuning the Bill, the industry expects the Government to make necessary amends that would not only root out corruption but also pave the best way forward for the future of medical education. Concludes Dr V Narendranath, Joint Secretary, The Con-sortium of Accredited Healthcare Organisa-tions, “A comprehensive NMC Bill, will be instrumental in monitoring the quality of medical institutions, thereby ensuring the quality of medical graduates and in turn the quality of healthcare delivery.”

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