THERE is no doubt that the Medical Council Act of 1956 was in need of urgent replacement. There were many reasons why such replacement was necessary. One trigger for recent attempts to change the Act was the high level of corruption. Even after Supreme Court strictures against leading individuals in the Medical Council, the influence of these individuals continued to grow. But the more important reason for having an effective professional council is the need to ensure that the nation has doctors and specialists who are responsive to peoples’ health needs and who deliver healthcare in the spirit of a public service. This should mean ensuring that a doctor’s decision on what treatment he or she prescribes should be dictated only by patients real healthcare needs and the individual or hospitals monetary interests should not have any influence on the clinical decision. The earlier medical council failed to play its regulatory role on the profession and failed to engage with these important issues.

However when introducing the National Medical Commission Bill, the government failed to take note of criticisms and amendments suggested by political parties, professionals and civil society to make an effective legislation.  On the other hand it introduced new clauses, which had not been submitted for scrutiny by either parliamentary committees or the public. The net result is an Act which seems to have left all the problems of the earlier Act intact, plus added a few of its own.

BUREAUCRATIC CENTRALISATION

One of the main problems of this new Act is the way it completely undermines the federal structure in medical education and professional regulation. The only elected members in 25-member commission are five members who are elected by representatives of state councils. Most commission members are nominated or selected through search committees appointed by the central government. To add to this, the Act gives the powers to the central government to give instructions to the commission on policies or overrule any policy made by the commission. The states have representation in a purely advisory body, the medical advisory council, but even this representation is limited to the vice-chancellor of the states medical university or if such university is not there, to a member nominated by the state medical council.

The commission has the powers to make rules and regulations for almost every operational detail across all states – and requires far greater institutional capacity than what any central institution of this nature has ever been able to demonstrate.

OPEN DOORS TO PRIVATE SECTOR

One major area of concern is that the bill explicitly allows ‘for-profit entities’ to establish medical institutions, thus legalising the establishment of medical colleges for the purpose of making high levels of profits. Further it limits the powers of the commission to framing guidelines for determination of fees to only 50 per cent of the seats in private medical institutions – which means that for half the seats the private institution can charge any level of fees. Even for this 50 per cent, there are no indications of what would be the principles of fee decision.  Such high fees not only excludes access to most of the poor and middle class, it also produces a graduate with no interest or obligation to enter into public services, and who has a high level of debt which can be recovered only by working in corporate hospitals and/or through corrupt practices and unethical care.

central problem with respect to availability of medical professionals is not the absolute numbers, but the big skew in distribution across states and within states, and between those available to provide services to the upper 10 per cent and those available to provide services to the rest. This skew cannot be resolved through private markets in healthcare education. Excessive production of doctors in some states and in some cities does not lead to their migration to less-served areas. It only leads to unhealthy competition in these few urban areas. Only a policy of expanding medical education to under-serviced areas through government owned institutions and bringing in candidates belonging to under-serviced communities through equity sensitive admission policies, followed by deploying these graduates in government owned facilities, can address the current mal-distribution. The Act does not even engage with this agenda. The design of this NMC Act of 2019, would only facilitate profits for corporate healthcare sector in medical education, and prioritise access to medical education for children of the very rich.

NEET AND NEXT: CENTRALISATION AND

EXCLUSION IN THE NAME OF QUALITY

respond to the public concern about how expansion of medical education, that too in the private sector, is undermining quality, and also because of its own obsession with centralisation, this Act mandates common national examinations for both entry and exit from medical education. With this Act, NEET (National Eligibility cum Entrance Examination), the common entry examination into MBBS course, gains legal status. As an entry test into the MBBS course, NEET does not help prioritise suitable candidates for under-served areas – which is a great necessity considering the highly skewed availability of human resources. Questions in the entrance examination are reported as favoring those educated in central school board examinations as compared to state school boards. This is why many states prefer to hold such common entrance examinations at the state level and surrender some 15 per cent of seats to a central pool for which a national examination would be relevant. But now states have to give up their state level entrance examinations. States also cannot consider admission based  only on school leaving marks of the school board examinations with some standardisation of marks across different boards.

of the big limitations of the Multiple Choice Questions (MCQ) format, which is used in such tests, is that selection of one correct answer among three or four very plausible alternative answers, within a timeframe requires skills and practice different from what it takes to understand a subject or write the usual examination. It thereby boosts the coaching industry and shifts the measure of merit towards the wealthier students who can afford such coaching. It also undermines the schools own final board examinations.

When the MCQ approach is applied as exit examination for the MBBS course, for licensing to practice (what is termed – NEXT – National Exit Examination), and the same examination is used for entry into post-graduation courses, these limitations of the MCQ increase.  Skills like clinical examination and communication with patients, which are central to qualifying as a doctor, do not lend themselves to MCQ tests. Further students pass different subjects in phases over five years, and to test them all in a single examination does not help. States use different forms of incentivisation and bonds for rural services for entry into post graduate education and these measures ensure that the state health departments get the specialists they need for public services. All of this is undermined in one go.

INDIFFERENT TO CORRUPTION

There is nothing in this Act that gives confidence that corruption would reduce. The proposal is for shifting inspections for accreditation from board members and medical experts to third party agencies, which could be commercial ventures.  This is more likely to change the form of corruption than eliminate it. The bill is also completely silent on kick-backs, commissions and other conflict of interests and unethical practices which urgently need to be addressed.

COMMUNITY HEALTH PROVIDERS AND THE IMA’S FEARS

One major new inclusion in the Act is the clause which allows for training and limited licensing to allow clinical practice to a newly created professional entity-called the mid level healthcare provider or the community health provider. The Indian Medical Association (IMA) is up in arms against this, and they label this as a form of permitting quackery. On the other hand, it is a fact that many developing nations, and even a few developed nations do have such a mid-level healthcare provider in place. This form of healthcare provider is one successful approach to providing healthcare in areas where doctors are scarce or unwilling to serve, and in providing assistance to doctors even in other areas, so that the doctors are freed to attend to more complex duties. However, most such nations which implement this, have a separate legislation and scheme for training and supporting such providers. There are such councils in place for nursing and pharmacists.  What this act (NMC-2019) does is to hurriedly pack an entirely new strategy into the Act without even providing definition of what the term means, what qualifications these new cadre of providers would have, and how the government would ensure that they would be limited to the geographical area and to the set of services for which they are licensed and how they would ensure that these providers are working only within government.  Without this clarity, it is quite likely that the IMA’s dire warnings of this scheme degenerating into quackery, would come true, and we would have one more poorly qualified healthcare provider in urban areas, rather than a well trained public health extension worker, prioritised for areas which doctors cannot reach.

POLITICAL POLICIES, NOT DOCTORS – ARE THE PROBLEM

In the public discourse that the ruling elite promotes, the poor functioning of the past medical council was due to some sort of inherent inability of the medical profession to govern itself. To some extent the medical professionals in the past medical councils brought this on themselves – by failing to check corruption and poor ethics.  But this is not the main reason for the failure of the past medical council. One problem was the lack of democratic participation from other sections of society and lack of transparency in its functioning, which remains even with this Act. 

The major problem, and the root of corruption, was however the privatisation of medical education and healthcare services that began in the nineties and which accelerated in this decade, which legitimised private profits in both medical education and practice.  In the last decade, the main thrust of government policy has been directed to shifting the role of the government from the role of provider of healthcare services to purchasing it from private providers through insurance or partnerships, and further promoting monopoly within the health care system. This in turn requires an expansion of the number of doctors available for recruitment by corporate healthcare providers – the creation of a reserve force of unemployed doctors who would keep doctors salary requirements down. Further studies and popular resentments are showing that private providers do not abide by contractual terms and that private educational institutions are overwhelmingly corrupt and of poor quality. Instead of seeing the roots of the problem in the policies of privatisation, the government would project the problem as entirely due to professionals and professional regulation. The failure to analyse or understand the other policy and systemic roots for problems like poor quality of medical education, corruption, ethical deficits, failure to generate human resources that are appropriate to our needs – all come together with an anti-professional bias to bring about a bill that satisfies no one, and solves very little.

As the government tries to implement this Act, these contradictions are going to intensify. As the central government has now taken over and centralised all powers of professional education and regulation, and further done this in parallel with promoting private healthcare services and private sector in medical education, the central government should be held accountable for the failures to provide affordable healthcare services, even by the private sector. Peoples movements which have fought for health rights as well professional associations and all democratic forces would need to exercise the utmost vigilance, and ensure timely public exposure of the limitations of this Act as it goes into implementation, and introduce into public discourse better options and alternatives for improving the numbers of appropriately trained and motivated medical professionals and the quality of care they provide.