blog 3

Healthcare dispensation in India has not exactly been in the best of health of late. It has been at the receiving end of numerous symptoms viz; over-corporatization, reluctance among healthcare dispensers to serve in rural hinterlands, privatization of medical education, corruption within the ‘watchtower’ of practice of medicine in India- the Medical Council of India(MCI). It was imperative that this vital, yet ailing sector be nursed back to health and vitality. The BJP-led NDA government attempted just that by passing the National Medical Commission (NMC) Bill, which was passed by the Rajya Sabha and Lok Sabha on August 1 2019 and July 29 2019 respectively. The Bill that was passed in good faith however, was not received well by India’s medical fraternity. Doctors owing allegiance to, and exhorted by the Indian Medial Association, (IMA), which draped the Bill with distinct ‘untouchability’, struck work across India.

blog 2

An earlier version of the Bill was introduced during the previous Lok Sabha and later referred to the Parliamentary Standing Committee on Health and Family Welfare. It lapsed with the dissolution of that Lok Sabha. The present government- popularly called Modi (2), referring to the popular sobriquet tagged to the ‘second innings’ of Narendra Modi as Prime Minister passed the bill, with a huge majority supporting it in Parliament. Is the bill truly an untouchable, as the doctors led by the IMA make it out to be?

Dissection of the various clauses of the bill will answer that question.

The NMC proposes to do away with the MCI, a body of elected members from among doctors, which according to the government is corruption-ridden to the core and one which has also failed in its various duties to safeguard and nurture ethical practice of medicine in India, and in regulating admission to undergraduate and postgraduate courses. Instead of the MCI, the NMC proposes to have four autonomous boards to take care of its different functions:

  • Undergraduate medical Education Board to set standards and regulate undergraduate medical education.
  • Postgraduate Medical Education Board to set standards and regulate postgraduate medical education.
  • Medical Assessment and Rating Board for inspection and rating of medical institutions. It is in this function of the MCI, that it has been charged with rampant corruption. Many a ‘Medical college’ of dubious standards, especially in the private and self-financing sector that lacks patients-popularly called ‘cases’ for students to study medicine on, and faculty of credible standards to impart medical education of reasonable quality has been given green signal to function by the MCI. The body was also in the habit of suspending recognition for well-conducted postgraduate and undergraduate courses in reputed medical colleges, especially in the public sector that the MCI itself had conferred earlier. Lack of uniformity by the MCI in granting recognition and permission to impart medical education to institutes always cast a shadow on the body, which was once the credible watchtower of medical practice in India. The IMA has reservations on this clause as the Board mooted in the NMC will be appointed by the government, while the MCI was a body elected by doctors themselves. The IMA’s concern is whether the government would henceforth usurp control of healthcare dispensation from doctors, who will actually be practicing medicine. Can the government be trusted with a Board entirely constituted by it, instead of the MCI, which had doctors on its board?
  • Ethics and Medical Registration Board to regulate and promote professional conduct and medical ethics and also maintain national registers of (a)licensed medical practitioners and (b)Community Health Providers (CHP)

CHPs are a new class of ‘medical practitioners’ proposed to be given licenses to practice modern medicine at mid level to those ‘connected with modern scientific medical profession’, the criteria of which would be specified later- a loose arrangement which leaves room for considerable suspicion. Their number would be 1/3 of the total number of licensed and registered medical practitioners. CHPs are proposed to be created out of those practicing indigenous medical systems (AYUSH), BSc nurses, B.Pharm and BDS graduates by imparting modern medical knowledge through a ‘Bridge Course’. This, rather revolutionary proposal was made necessary as the government was concerned about the dwindling doctor:patient ratio especially in the villages, denying credible healthcare to citizens residing in Indian Hinterlands. It is a stark reality that doctors practicing modern medicine do not consider it their responsibility to serve in villages, where majority of Indians reside. This reluctance has resulted in Gross disparity between numbers of doctors qualifying and those actually available to work in government hospitals, which are located in the villages. Every year 55,000 doctors complete their MBBS and 25,000 complete post graduation nationwide. If this is true, India ought to have had an allopathic doctor for every 1,250 people for a population of 1.3 billion by 2020, and one for every 1075 by 2022. But reality falls far short of this. There is clustering of tertiary care ‘super-specialty’ hospitals, especially in the corporate sector in larger towns and cities, where health care of citizens living therein is adequately addressed.

This is the clause in the NMC which has received IMA’s most vehement objection. The objective to create CHPs, it argues would further quackery. But, with doctors graduating with basic undergraduate modern medical degree reluctant to serve in government facilities in the villages, the government attempted to undo this gross, and to a certain extent unfair disparity by creating CHPs. After all, Indian healthcare, especially in the villages largely demand basic medical care, which includes primary preventive strategies like immunization, antenatal, first aid services, basic surgical, medical and obstetric services, which can be easily provided in a basic facility manned by adequately trained personnel. Nobody expects gadget or facility-heavy services to be offered in government health facilities in the villages, which actually will do well with a well-run basic medical service. This is not to say that high-end tertiary care shouldn’t be provided in the villages through public hospitals there. Indeed, complex procedures like heart transplantation in September 2015 and surgical separation of conjoint twins in June 2012 have been undertaken in Government Medical College Hospital in Kottayam in Kerala, and a missionary hospital in Betul in Madhya Pradesh, respectively .Basic medical services, which are beyond a vast majority in India can be offered by well-trained CHPs, which the government sought to achieve through this clause. But, can the government be trusted with regulation of CHPs? Would they attempt to undertake more complicated medical services like surgery, which would create mayhem in healthcare sector in India? That would amount to quackery. The government mustn’t get carried away in its endeavor to equip indigenous medical practitioners with ‘more skills’. Who would monitor the CHPs? How can more skill-heavy and complicated modern medicine and it’s practice be entrusted with B.Pharm, BDS and B,Sc nursing graduates? It cannot be! But, the IMA needs to realize one stark reality before airing its reservations and protests about and against this clause. Are the so-called undergraduates and postgraduates graduating from ‘medical colleges’, run by private and the so-called ‘self-financing sector’ operating in ramshackle kiosks, be entrusted unreservedly with modern medicine and its dispensation? Many who graduate as qualified modern medical practitioners do so by not seeing enough patients to hone their skills, nor are they imparted medical training by competent faculty. Doesn’t that amount to quackery in a sense?  Modern medical dispensation in Indian villages can be adequately provided by CHPs, provided their ‘services’ and realm of practice of medicine is well regulated. Can the government be trusted with this Herculean task?

As for admissions and licensing, the Bill provides for a National Eligibility-cum-Entrance test (NEET) for admission to all undergraduate and postgraduate super specialty medical education, while providing for another one, National Exit Test (NEXT) for granting ‘license’ to practice and admission to postgraduate broad-specialty courses. So far, admissions are through the NEET and no licensing is required to practice.  The medical practitioner has only to register with a state medical council to practice.

As a matter of fact, the proposed NEXT condenses the final year qualifying MBBS examination, NEET and a licensing test into a single test, which will be an objective test. The distinct disadvantage in this proposal is that the crucial practical part of the present qualifying MBBS exam in the final year would lose its importance. Secondly, NEXT has the potential to deny candidates from reappearing in the NEET, through which admission to postgraduate courses are secured. NEXT being an objective type examination will mandate students doing basic undergraduate MBBS course to sharpen their knowledge and to be more focused to medical science to clear the exam. This will definitely separate the chaff from the wheat from among undergraduates qualifying from various ‘medical colleges’, thereby furthering the quality of medical graduates. After all, numerous countries have native licensing examinations before doctors can practice there.

The bill also proposes for the NMC to frame guidelines for determination of fee and other charges for 50% of seats in private medical institutions and deemed universities. Currently, state governments determine fees for 85% of seats in such institutions, and the rest are left for the managements. Other powers of the NMC include permission to establish new medical colleges, start postgraduate courses, increase the number of seats, recognition of medical qualifications in and outside India. With corrupt legislators themselves owning ‘medical colleges’ in private and self-financing sectors, making lucrative business out of ‘medical education’, the above said functions of the NMC to regulate and decide fees, and permission to establish new medical colleges will be akin to handing over the keys of the house to robbers! They’ll run roughshod over medical education in the country and create hara-kiri out of it unless somebody decides to shackle them. But, can the government be trusted to bell the cat?