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National Medical Commission Bill, 2017

A Shattered Hope?

Pradip Mazumder (bengal.star@yahoo.com) is an activist at the Federation of Medical and Sales Representatives’ Associations of India. He blogs about medicine and health-related issues at pradipsinterpretations.blogspot.in.

The National Medical Commission Bill, 2017, which aims to overhaul medical education in India and replace the 83-year-old Medical Council of India with a government-appointed NMC, has several worrying features. While the long-term implications of the bill have not been satisfactorily debated and addressed, the bill itself is in danger of causing similar or even worse outcomes than the previous MCI Act. The NMC Bill remains a questionable remedy, and it has drawn criticism from several quarters, including the country’s medical fraternity.

Following disagreement, the Lok Sabha has decided to send the draft of the National Medical Commission Bill (2017) to the Parliamentary Standing Committee (PSC) on Health for review. The draft bill, which was introduced by Minister of Health and Family Welfare J P Nadda in the Lok Sabha on 29 December 2017, and in the Rajya Sabha on 2 January 2018, seeks to repeal the Indian Medical Council Act, 1956, and paves the way for setting up a National Medical Commission (NMC) that would replace the Medical Council of India (MCI). In protest, the Indian Medical Association (IMA) observed a “black day” on 2 January, calling the bill draconian, undemocratic, unrepresentative, and contrary to the federal polity of the Constitution (ANI 2018). On the day, around 2.9 lakh doctors across the country held a 12-hour strike. In his media briefing, K K Aggarwal, former president of the IMA, said that their next step would be to convince the standing committee of the many flaws in the bill (Koshy 2018).

This article briefly deals with some of the major flaws of the bill.

Background of the NMC Bill

The draft bill was created in response to increasing criticism of the functioning of the MCI by several stakeholders, including the Supreme Court (Rajagopal 2016). The MCI, a statutory body, was established in February 1934 under an act of Parliament termed the Indian Medical Council Act, 1933. This act was repealed by the Indian Medical Council Act, 1956, which was subsequently amended in 1964, 1993, and 2001. The objectives of the MCI may be briefly described as maintaining uniform standards of medical education; recognising or derecognising medical institutions; regulating the professional conduct of medical practitioners, etc. However, instead of attracting eminent and talented professionals, the MCI, over the years, has been captured by a small clique that have been charged with corruption and nepotism. While many of its members have been accused of taking bribes in exchange for granting accreditation to aspiring medical colleges in India, the MCI has also been deemed one of the most corrupt regulatory institutions in the country. Even its former chief, Ketan Desai, was charged with accepting a bribe for granting affiliation to a Gyan Sagar Medical College, a private medical college in Patiala, in 2010 (Times of India 2010; Economic Times 2010).

Given the degree of discontent and pile up of grievances, the government decided that it was necessary to reform the MCI and create differentiated boards to regulate aspects like undergraduate and postgraduate education; accreditation and licensing; and ethical practice; while providing a platform for cross-consultation and coordination between medical and non-medical personnel and their disciplines. Former Prime Minister Manmohan Singh, in his Independence Day Speech in 2009, mooted the idea by proposing a comprehensive National Commission for Human Resources for Health. In 2013, the PSC returned the bill stating that it entailed excessive bureaucratisation and centralisation; was against federal principles as it undermined states’ autonomy; and featured a faulty selection procedure that provided scope for abuse (Rao 2018).

In response, the present government at the centre constituted an expertcommittee in 2014 under Ranjit Roy Chowdhury to finalise the draft (NITI Aayog 2016). Thereafter, since nothing had happened to correct the state of affairs in the MCI, the PSC suo motu submitted a report, sharply recommending the implementation of Chowdhury’s report (2016). But the government formulated another committee under the chairmanship of Arvind Panagariya, vice-chairman, NITI Aayog, with three other members: (i) P K Mishra, additional principal secretary to the Prime Minister; (ii) Amitabh Kant, chief executive officer (CEO), NITI Aayog; and (iii) B P Sharma, secretary, Department of Health and Family Welfare, who would act as its convener. The committee was tasked with suggesting reforms to improve outcomes in medical education in India. Instead, the committee came up with a draft bill and published the same in August 2016 on a website for comments, which reportedly received an estimated 22,000 responses (Sharma 2016).

Subsequently, a group of ministers (GoM) chaired by the finance minister examined the draft. And, finally, the cabinet, in its meeting on 15 December 2017, consented to place the NMC Bill in both houses of Parliament. While the draft NMC Bill has failed to rectify the issues in the MCI in compliance with the observations made by the PSC, it has introduced a host of issues which cause further anxiety and anger.

Excessive Central Dominance

Presently, the MCI constitutes one member from each state nominated by the central government in consultation with the concerned state government; one elected member representing the union territories; one member from each university elected by the senate, court, or equivalent body of that university; one member with medical qualifications elected from each state from among the registered medical practitioners of that state; and eight members nominated by the central government (Table 1).

In addition, there are eight MCI officers appointed by the Government of India. As on 1 April 2017, the MCI had 112 regular and 65 contractual employees. The president and the vice president of the MCI are elected by the members from among themselves. The executive committee may also be considered an elected body, as of its 11 members, only three are nominated while eight are elected.

In contrast, the proposed NMC will be a nominated body. The central government shall appoint the NMC and shall, through notification, establish autonomous accreditation boards under the general supervision of this commission. General superintendence, direction, and administration of the commission shall be vested in the chairperson. The central government shall appoint the chairperson, presidents of the boards, part-time members, and the member secretary through selection by a search and selection committee. Again, the central government shall constitute the search and selection committee, which will consist of the cabinet secretary; CEO, NITI Aayog; two persons nominated by the Ministry of Health and Family Welfare (MoHFW), and the secretary of the MoHFW, as the convener. In short, a 25-member commission selected by a search committee and headed by a union cabinet secretary will replace the elected MCI. This bureaucratic structure could possibly dent the autonomy of the proposed commission (Table 2).

By splitting the selection, advisory, and accreditation process into three separate boards, the bill aims to create a system of checks and balances. However, all the members of the accreditation board are considered to be ex-officio members of the advisory board. This means that instead of having different boards that can monitor and regulate each other, the NMC would have a singular body with two different heads, the possible corruption potential of which contravenes any arguments about good governance. Moreover, a shift from the elected MCI to the nominated NMC—a shift perhaps from a democratic system towards an autocracy—does not bode well, either.

Commercialisation of Medical Education

According to the MCI website, out of the 479 medical colleges in India, only 213 colleges are controlled by the government, suggesting that the country’s medical education has already moved from the public to the private domain; this is despite the huge investment required—more than `400 crore—to set up a medical college. To recover their investment, the NMC Bill allows the management of medical colleges unbridled power and freedom to charge any quantum of fees for 60% of the seats. Pro-government stakeholders may argue that this would attract more investments to the field, but the logic is debatable. Rather, the government appears to have greenlighted corporate greed-driven overcharging of capitation fees, while simultaneously supporting the monopolising of medical education by the rich. In addition, corrupt practices are likely to increase. Since medical education is directly linked to public welfare, corruption in healthcare regulatory bodies has direct consequences for the quality and cost of healthcare services. Therefore, the government should introduce strict regulations and innovative enforcement mechanisms to regulate the profiteering of private medical colleges and ensure universal access to medical education.

NEET: A Crucial Move

The bill proposes a uniform National Eligibility cum Entrance Test (NEET) to determine admission to undergraduate medical education in all medical institutions and also outlines the process for conducting national-level common counselling for all candidates.

Arguably, such a pan-India entrance test would ensure that “merit” is the only criterion for admittance to medical education and would produce medical practitioners of similar pedigree, while bringing an end to corrupt and unethical practices that have been in existence for decades, predominantly in private medical colleges.

Such an argument is pointless since medical entrance exams do not make doctors. In order to achieve uniformity among medical practitioners, the quality of medical education and training must be standardised and improved. Paradoxically, the NMC Bill allows medical colleges to increase their intake capacity without providing evidence of adequate humanpower, infrastructure, and other resources. As per the provisions of the bill, medical colleges will not need to seek permission to add new seats or start postgraduate courses. It is beyond anybody’s imagination as to how such provisions would curtail corruption in medical institutions. The bill also allows medical institutions to escape charges of non-compliance for up to three times by paying monetary compensation.

Moreover, NEET, while dismantling proficient and acclaimed state medical boards, will also create an ecosystem that favours students who are predominantly urban, rich, and upper caste, and who can afford the private tuition classes needed to score highly in such entrance exams. Medical entrance coaching is already a booming business, and accusations of there being a corrupt nexus of coaching centres and medical colleges has raised questions about conflicts of interest. Enforcing NEET will certainly result in the mushrooming of such corrupt and highly priced coaching centres beyond the reach of most talented students. Thus, under the pretense of merit, medical education will be made selectively available to privileged social elites.

National Licentiate Examination

Conducting a uniform National Licentiate Examination (NLE) for the professionals graduating from medical institutions to grant them license to practise and enroll themselves in medical register(s), is perhaps the most controversial proposition of the bill. The examination shall become operational within three years from the date on which the act comes into force, and shall also serve as a NEET-PG for admission into postgraduate courses in medical colleges and institutions under the purview of the NMC. It has been argued that such an examination is necessary to filter future medical practitioners by quality and is, therefore, a welcome move. However, this argument is also contentious.

First, according to the provisions of the bill, MBBS doctors in India have to compulsorily pass NLE in order to obtain their licenses, while the NMC can exercise its discretionary power to grant licenses to students graduating from overseas colleges. The commission also holds arbitrary power to permit individuals to practise medicine or perform surgery for a certain period of time without qualifying NLE. Such powers allow for discrimination and a high degree corruption.

Second, an undergraduate medical student has to clear over 10 examinations to get an MBBS degree. How will one more theory exam ensure the quality of medical practitioners in the country? In lieu of such an examination, hands-on training is more important, and the NMC must lay out a plan for the same. Amidst this long-standing feud, wide variations in the quality of medical education across the country goes neglected. When the draft bill recognises that the stringent criteria that need to be met for opening a new medical college may be relaxed for those set up in an unserved area, there is a contradiction in treating all medical students at par.

Third, NEET-PG should not be used as a licentiate exam for medical graduates. Presently, all MBBS graduates do not appear for the all-India post-graduation examination. Rather, most of them choose to work in primary health centres in villages. Those who pursue postgraduate medical degrees usually move to urban areas. The government’s attempt to make NEET-PG a licentiate exam will incentivise MBBS graduates to move to urban areas and pursue post-graduation. This may affect the delivery system of rural health services.

Fourth, MBBS graduates, instead of preparing for NLE, may choose to seek jobs in European and other countries that offer much better pay packages. With a little more effort (than preparing for NLE), if one can crack the USMLE (United States Medical Licensing Examination), the earning potential of that student would increase at least by 10 times compared to what the Government of India pays an MBBS student. So, further migration of doctors to various countries may increase.

India has already become the largest source of physicians in the United States and the United Kingdom, second largest in Australia, and third in Canada. The NLE may actually reduce the number of qualified medical practitioners available in suburban and rural areas.

AYUSH Apathy

India has less than one doctor (0.620:1000) for every 1,000 population, which is below the minimum standard set by the World Health Organization (1:1000) and worse than Pakistan at 0.806:1000 (Indian Express 2017). Given the urgent need to address the primary health needs of communities which are now largely managed by unqualified quacks, the government has been requesting the MCI, since 2010, to institute new cadres of public health personnel along the lines of the LMPs (Licentiate in Medical Practice) during the British days. Instead, the NMC Bill intends to design “bridge courses” legalising AYUSH (mainly Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy), practitioners to prescribe allopathic medicines.

Like the MCI which deals with the allopathic vertical, the Central Council of Indian Medicine (CCIM), a statutory body under the Department of Ayurveda, regulates the practice of “Indian systems of medicine” like Ayurveda, yoga and naturopathy, Unani, Siddha, etc; in addition, the Central Council of Homoeopathy (CCH), a statutory body under the MoHFW, regulates homoeopathy medicines and practitioners in India. States have independent boards for each stream of medicine which function like independent medical councils with elected office-bearers to regulate education and practice in their respective stream.

The draft bill proposes that the heads of the NMC, CCIM, and CCH, in a meeting, design such “bridge courses” and approve them by a simple voice vote of those present, to enable all AYUSH practitioners at all levels, primary to postgraduate, to prescribe allopathic medicines, endangering the credibility of all systems of medicines. Not only has the IMA vociferously protested the proposal, the government’s own CCH has also expressed its opposition to offer homoeopaths licence to practise limited allopathy, reiterating its “consistent and complete” opposition towards any crossover between homoeopathy and allopathy (Bhuyan 2018). The CCIM has supported the bridge course, stating that it would give AYUSH practitioners access to technologies like anesthesia, radiology, ultrasound scans, and magnetic resonance imaging (MRI), useful for the “advancement” of Ayurveda (Bhuyan 2018; Kohli 2018). However, scepticism prevails that this attempt to reduce the shortage of doctors might open a new legal channel to produce “qualified medical quacks” in the name of medical pluralism.

NMC’s Medical Assessment

The new bill suggests that assessments of medical teaching institutions is to be done through an autonomous board, namely the Medical Assessment and Rating Board, which the central government shall establish by notification. However, the board is not given direct jurisdiction over the accreditation process. Instead, four sub-boards shall control core areas such as accreditation for undergraduate and postgraduate courses, maintaining a register of medical practitioners, and compliance. In order to discharge its assessment and rating function, the NMC shall hire credible third-party agencies or appoint visitors and personnel to carry out inspections of the medical educational institutions. Such an assessment and rating function may induce large-scale bureaucracy and may choke the process of accreditation. Moreover, inspection through third-party agencies may invoke large-scale corruption.

Conclusions

One would expect that the NMC Bill, drafted by NITI Aayog, would bring about radical reforms in the country’s medical education system, which is allegedly ridden with corruption and unethical practices. But the bill is not the right remedy to achieve the expected benchmark. Instead, if the bill is implemented, a dearly priced medical education system, run privately, would emerge, further decreasing the scope of universal accessibility of medical education and future enrolment. However, besides its many limitations, the greatest concern relates to the centre’s agenda in proposing these reforms. The present regime is out to bring the country’s entire education system under its control. Thus, schools in India are forced to conduct centrally sponsored Teachers’ Day events and Sanskrit Week, broadcast the Prime Minister’s radio speeches to students, conduct yoga days and so on; in addition, distorted historical and sociological facts are being introduced through textbooks. Hence, the move to replace an elected medical council with an appointed commission to regulate the country’s medical education system certainly fuels apprehensions about institutionalising autocracy and at the cost of democratic advantage and ethical values. The NMC Bill aimed to reform the MCI and create a world-class medical education system in the country. However, with its existing deficiencies, the bill appears to be a shattered hope.

References

ANI (2018): “National Medical Commission Will Affect Future Docs, Patients: IMA President,” 2 January, https://www.aninews.in/news/national/general-news/national-medical-commission-will-affect-future-docs-patients-ima-president201801021849250002/.

Bhuyan, Anoo (2018): “Govt Homeopathy Body Slams ‘Bridge Course’, Indian Medicine Council Supports Different Idea of It,” Wire, 11 January, https://thewire.in/212829/govt-homeopathy-body-slams-bridge-course-indian-medicine-council-supports-different-idea-of-it/.

Department-Related Parliamentary Standing Committee on Health and Family Welfare (2016): “Ninety-Second Report: The Functioning of Medical Council of India (Ministry of Health and Family Welfare),” Rajya Sabha Secretariat, New Delhi, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on
%20Health%20and%20Family%20Welfare/92.pdf
.

Economic Times (2010): “Medical Council of India Chief Arrested on Bribery Charges,” 24 April, https://economictimes.indiatimes.com/news/politics-and-nation/medical-council-of-india-chief-arrested-on-bribery-charges/articleshow/5850982.cms.

Indian Express (2017): “Less Than One Doctor for 1000 Population in India: Government Tells Lok Sabha,” 21 July, http://indianexpress.com/article/india/less-than-one-doctor-for-1000-population-in-india-government-tells-lok-sabha-4760892/.

Kohli, Namita (2018): “NMS Bill Exposes Fear and Biases among Medicos,” Week, 10 January, http://www.theweek.in/news/india/nmc-bill-debate-exposes-fears-biases-and-confusion-among-medicos-ima.html.

Koshy, Jacob (2018): “Doctors Call Off Strike after Government Defers National Medical Comission Bill,” Hindu, 2 January, http://www.thehindu.com/news/national/doctors-call-off-strike-after-government-defers-national-medical-commission-bill/article22353837.ece.

Medical Council of India (nd[a]): “Council Members,” https://www.mciindia.org/ActivitiWebClient/aboutus/councilmembers.

— (nd[b]): “List of Colleges Teaching MBBS,”
https://www.mciindia.org/ActivitiWebClient/informationdesk/listofCollegesTeachingMBBS.

NITI Aayog (2016): “A Preliminary Report of the Committee on the Reform of the Indian Medical Council Act, 1956,” Government of India, http://niti.gov.in/writereaddata/files/document_publication/MCI%20Report%20.pdf.

Rajagopal, K (2016): ‘Supreme Court Panel to Monitor MCI,” Hindu, 3 May, http://www.thehindu.com/news/national/Supreme-Court-panel-to-monitor-MCI/article14297426.ece.

Rao, K Sujatha (2018): “Dangers of Old Indian Medical Council Act Remain in New National Medical Commission Bill,” Wire, 5 January, https://thewire.in/210859/national-medical-commission-bill-2017/.

Ravi, Shamika, Dhruv Gupta and Jaclyn Williams (2017): “Restructuring the Medical Council of India,” Brookings India Impact Series, Brookings Institution India Centre, New Delhi, https://www.brookings.edu/wp-content/uploads/2017/08/mci-impact-series-paper.pdf.

Sharma, Yogima Seth (2016): “NITI Seeks Public Opinion on National Medical Commission Bill,” Economic Times, 10 August, https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/niti-seeks-public-opinion-on-national-medical-commission-bill/articleshow/53631942.cms

Times of India (2010): “MCI Chief Arrested for Taking Rs 2 Crore Bribe,” 24 April, https://timesofindia.indiatimes.com/india/MCI-chief-arrested-for-taking-Rs-2-crore-bribe/articleshow/5850284.cms?

Updated On : 5th Feb, 2018

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