THE National Medical Commission Bill, 2017, recently approved by the union cabinet, has now been referred to a parliamentary standing committee after protests by various sections of the medical profession.  The bill is designed to replace the Indian Medical Council Act of 1956. The bill was drafted in the aftermath of several scandals that rocked the Medical Council of India in the past decade. These include the arrest by the CBI of the then president of the Medical Council of India (MCI), Ketan Desai, in 2010 on serious charges of bribery related to approval provided for a private medical college.  A report of the Parliamentary Standing Committee on Health and Family Welfare (Report 92 submitted to the Rajya Sabha on March 8, 2016) had recommended a complete overhaul of the system of regulation of medical ethics and medical education (the twin functions of the MCI). The report noted that “The committee takes note of the admission of the president of MCI that corruption is there when there is sanctioning of medical colleges or increasing or decreasing of medical seats”. It further said that “it seems the MCI has become captive to private commercial interests, rather than its integrity in public interest (sic)."

RESPONSE TO REPORTS OF CORRUPTION IN THE MCI

Given its extremely murky past it is impossible to hold a brief for the current MCI. It is arguably one of the most corrupt regulatory institutions in the country. The MCI, over the years, has become a seat of corruption and has been captured by a small lobby of private medical practitioners. Instead of attracting professionals of high calibre, the MCI came to be run by a coterie that was secure in the belief that they would be protected by politicians and bureaucrats at the highest levels.

Some of the key proposals in the NMC Bill 2017, it is claimed, address deficiencies embedded in the Indian Medical Council Act of 1956. It is proposed that the twin functions of the MCI – regulation of medical education and regulation of ethics would be separated. The bill proposes setting up of an apex body, the National Medical Commission, which would oversee the functioning of four separate boards. These boards would deal, respectively, with under-graduate and post-graduate education (under-graduate and post-graduate medical education boards), assessment and rating of medical institutions (Medical Assessment and Rating Board) and registration of medical practitioners and enforcement of medical ethics (Board for Medical Registration). This appears to be a logical proposal given that the principal source of corruption was located in the process of granting and renewing necessary permissions to run medical colleges, and vitiated the role of the MCI as an institution tasked with regulating medical ethics.

CONTENTIOUS PROPOSAL IN THE BILL

Some of the other proposals in the bill are more problematic. Reform of the MCI could have resulted in effective democratisation of the apex body for regulation of medical ethics and education, by making space for professionals, academics and social activists. Instead the prescription offered in the NMC Bill, 2017, is to create a structure that is packed with ex-officio members nominated by the government –only three members of the apex 25 member commission will be elected by members of the medical profession. This is a major departure from the way the MCI was constituted, where all registered medical practitioners had the opportunity (at least theoretically) to elect most of the members of the MCI. It is true that the process was captured by a small lobby which faced serious charges of corruption and nepotism. However it is not clear how the National Medical Commission, consisting largely of members who are nominated in various ways by the government and the health bureaucracy, will be kept free of corrupt influences. If a system of democratic representation can be twisted to serve vested interests, there is no guarantee that a body consisting largely of nominated members will be free of corrupting influences.

The MCI was modeled on the General Medical Council (GMC) of the UK. The GMC does include members appointed by the government, but a majority of members are elected by Registered Medical Practitioners in the UK. Similar structures exist in countries such as Australia, New Zealand, Singapore, South Africa, etc. The functioning of these councils indicate that a largely elected council need not be prey to corrupting influences. That the government has chosen to pack the proposed new council with its own appointees indicates that it wishes to exercise complete control over the new council. This is fraught with several serious consequences and would in no way contribute to democratic control of regulatory structures related to the medical profession. Given the propensity of the government of the day to centralise decision making and capture public institutions by converting them into appendages of the ruling party, this key aspect of the National Medical Commission Bill needs serious scrutiny.

PROMOTING PRIVATISATION

While the fountainhead of corruption in the existing MCI is linked to the rapid privatisation of medical education in India since 1990, the proposals in the bill encourage further privatisation. In 1980 there were 100 government run medical colleges and just 12 private colleges, accounting for 16,570 and 1,770 undergraduate seats respectively. By 2016 there was an almost cataclysmic shift in this ratio – 205 government run medical colleges with 27,490 under-graduate seats as against 221 private colleges with 24,690 under-graduate seats. Instead of advocating for much enhanced public investment in medical education, the NMC Bill proposes relaxation of regulatory measures to ensure that medical colleges adhere to notified standards and the main beneficiaries would be private colleges, many of them with a long track record of corrupt practices. The new bill does not require already registered colleges to seek prior permission before increasing seats in under-graduate and post-graduate education.

The proposals regarding private medical colleges in the bill need to be understood in conjunction with steps undertaken in the past years to ease the entry of for-profit organisations – including corporations – in the medical education sector. In 2012, in a departure from earlier practice, companies registered under the Companies Act were permitted to set up medical colleges. However a caveat was added that the colleges could not “resort to commercialisation” meaning that these could not be profit making ventures.  In 2016 a committee set up under the aegis of the Niti Aayog said, "Currently, only ‘not-for- profit’ organisations are permitted to establish medical colleges...  the Committee recommends delinking the condition for affiliation / recognition from the nature of the promoter of the medical college”. The health ministry, acting on this proposal, had subsequently written to the Medical Council of India to substitute Sub Clause (6) of the eligibility criteria to remove the reference to ‘commercialisation’. The NMC Bill takes forward the move to legitimising profit-making in medical education by proposing that the NMC would: “frame guidelines for determination of fees in respect of such proportion of seats, not exceeding forty per cent., in the private medical institutions and deemed universities which are governed by the provisions of this Act”. In other words this provision provides legal clearance to private medical colleges to charge exorbitant fees for 60 per cent of seats. Clearly the NMC Bill embodies a vision for medical education that does not include higher public investments but rather clears the way for converting medical education into a lucrative profit-making venture.

PROTESTS BY THE INDIAN MEDICAL ASSOCIATION (IMA)

The IMA has opposed adoption of the bill on several grounds, some of them in line with issues raised above regarding democratic constitution of the NMC. Unfortunately IMA’s credentials to speak about the MCI have been severely dented, given their silence and even tacit approval of corrupt practices in the MCI. The body was responsible for condoning Ketan Desai’s acts by proposing his elevation as president of the World Medical Association.

The IMA has also opposed a proposal in the bill that would allow Ayush practitioners (graduates in Ayurveda, Siddha, Unani and Homeopathy) to practice modern medicine after a bridge course. This proposal appears to have been inserted in haste, without thinking through the possible consequences. Education in the Ayush systems is in an even worse shape that in modern medicine. Further, Ayush systems, especially Homeopathy, are based on principles than are very different (sometimes diametrically opposite) from those that underpin the study of modern medicine. An Ayush graduate, if licensed to practice modern medicine, would be required essentially to unlearn almost all the fundamental tenets of the system she or he has trained in. How a bridge course shall ensure this, is beyond comprehension. The problem lies in the fetish to create more ‘doctors’ at any cost, without regard for the quality of such ‘doctors’. What is needed is a different policy towards ‘alternate’ systems as well as human resources for healthcare in general. If graduates of alternate systems are to be optimally deployed, their curriculum and training as well as avenues for their utilisation in the country’s health system need to be thoroughly debated and revamped. It is illogical to train someone in a particular system for four to five years and then expect the person to be adept in an entirely different system within six months. What is actually needed is to train and deploy a much larger number of nurses, midwives, and health workers. These workers need to be trained to perform tasks within the health system that we mistakenly believe can only be performed by doctors. Above all they must be adequately remunerated, unlike the present practice where many cadres of health workers (ASHA workers for example) are paid a pittance.

To summarise, the NMC Bill is designed to address the long standing criticism about corruption in the MCI. It incorporates some useful mechanisms such as bifurcating the functions related to regulatory issue and those that deal with the upholding of medical ethics. However, it seeks to create an institution that centralises power within the government and the bureaucracy and at the same time provides major concessions to promote the privatisation of medical education. Many of its proposals are in the nature of a ‘quickfix’ and avoid deeper systems change. In its proposed form the National Medical Commission will not serve the interests of healthcare and medical education in India. It is hoped that the standing committee will curb two prominent ambitions in the bill – absolute control by the central government of medical regulation, and promotion of the private medical sector.