ED CLASS 2 LUKMAAN IAS

CSE 2019 14

TOPIC 3: REFORMS IN HEALTHCARE REGULATORY BODY (MCI)

THE CONTEXT

Recently, the government replaced the top tier of the management of the Medical Council of India (MCI) with a new board of governors and has floated a National Medical Council (NMC) Bill to reform the MCI. This article will try to explain the pros and cons of the bill and way forward to it.

WHAT IS MCI?

The Medical Council of India (MCI) was established in 1934 under the Indian Medical Council Act, 1933, which was repealed and replaced by the Indian Medical Council Act, 1956.

The main functions of the council include the maintenance of uniform standards of medical education, recognition/de-recognition of medical qualifications and medical colleges, and the registration of doctors.

TIMELINE OF NATIONAL MEDICAL COUNCIL EVOLUTION

Till 2010 The Medical Council of India (MCI) was repeatedly criticized for providing opaque accreditation to aspiring medical colleges in India.

Many of its members have been accused of taking bribes in order to fast-track accreditation that compromise medical college quality overall in the country.

Delhi HC calls MCI as a Den of Corruption in 2001.

2014 Govt. constitutes an expert committee under Dr Ranjit Roy Chaudhury

2016 The Supreme Court sets up a three-member oversight committee headed by former Chief Justice of India RM Lodha to guide the MCI in its functioning, with a tenure of one year.

It proposes to introduce the National Exit Test (NEXT) for MBBS graduates to qualify themselves as doctors and to secure registration for clinical practice.

Later on, the SC directs the government to set up an oversight committee with the authority to oversee all statutory functions of MCI.

2017 Parliamentary standing committee submits the report. in the Rajya Sabha along with its recommendations.

Based on this, the NITI Aayog Committee starts drafting a National Medical Commission Bill (2017) to replace the Indian Medical Councils Act (1956)

Jan 2018 NMC Bill (2017) tabled in Lok Sabha. Faces huge oppositions from medical fraternity and hospitals.

Sept 2018 Govt. calls for Ordinance and appoints a committee to run MCI till the legislation is passed.

NEED FOR ORDNANCE

a) The ordnance aims to provide for the replacement of the board of MCI for a period of one year through a Board of Governors (BoG), which will exercise the powers of the MCI.

b) The BoG will be made up of seven members including persons of eminence in medical education, appointed by the central government. The central government will select one of these members as the Chairperson of the Board. Currently, it is headed by NITI Aayog member V.K. Paul

ED CLASS 2 LUKMAAN IAS

CSE 2019 15

c) Further, the Ordinance provides for the Board of Governors to be assisted by a Secretary General appointed by the central government.

PROPOSED STRUCTURE OF NATIONAL MEDICAL COUNCIL AS PER THE NMC BILL (2017)

a) The NMC Bill provides for distribution of functions of MCI among 25 members and four autonomous boards.

b) A Search Committee will recommend names to the central government for the post of Chairperson and the 5 part time members of NMC.

c) 5 members (part time) will be elected and will not be a part of any board. Other 20 would be selected through a transparent process based on their merit.

d) These 20 members will comprise a Chairperson, a member secretary, eight ex-officio members and 10 part-time members.

e) Out of the 8 ex-officio members, four shall be presidents of the autonomous boards constituted under the act and remaining four shall be nominees from three ministries viz. Health, Pharmaceuticals, HRD and one from Director General of Health Services.

f) The boards would split the selection, advising, and actual accreditation process of the curriculum and colleges for medical education into three separate boards. The fourth one will focus on ethical conduct of medical practitioners

g) The accreditation board will act as advisory board and does not have direct jurisdiction over the accreditation process. It can do it indirectly through four sub boards (1) UG course (2) PG course (3) ethics and registration of practicing medical professionals (4) compliance wing.

h) The Ethics and Medical Registration (EMR) board shall maintain a separate National Register including the names of licensed AYUSH practitioners and allopathic doctors.

i) The compliance wing under the accreditation board is supposed to hire a third party to check that colleges meet standards set by the other sub-boards.

HIGHLIGHTS OF THE BILL

Spur growth of pvt. medical seats by

removing license-permit quota raj

• The bill allows NMC to determine fees for up to 40% seats in pvt. medical institutions and deemed universities while allowing the rest 60% to be regulated by the institutions themselves.

• This is expected to spur rapid growth in the number of medical seats in the country by attracting investments, by easing the entry of new colleges and allowing automatic expansion of seats up to max. 250 nos. in the existing colleges.

Uniform qualification criteria

• The Bill calls for setting up a National Licentiate Examination for doctors to obtain a license to practice after graduation.

• This examination will also be the basis for admission to post-graduate medical courses.

Resolve shortage of docs in critical areas

• The NMC can permit a medical professional to perform surgery or practise medicine without qualifying the National Licentiate Examination, in circumstances that may be specified in regulations.

Resolve shortage of faculties

• The bill establishes full parity between the degree conferred by the National Board of Examination (called as Diplomate of National Board (DNB)) and the one by the National Medical Commission.

• This feature will allow the DNB holders to serve as faculty members in medical colleges and thereby alleviate the current faculty shortage

Grievance redressal • State Medical Councils will receive complaints relating to professional or ethical misconduct against a doctor.

ED CLASS 2 LUKMAAN IAS

CSE 2019 16

• If the doctor is aggrieved of a decision of the State Medical Council, he may appeal to successively higher levels of authority.

CRITICISM OF THE BILL

Short term approach

• The current bill brazenly favors the private sector to fill the gap in medical seats.

• It fails to improve the quality of the existing assets in public sector medical colleges and hospitals that are decaying for want of support and encouragement.

Lack of comprehensive

approach

• The bill fails to recognize the role of nonmedical interventions in health care such as infrastructure (roads, transport etc.) nutrition and availability of food; safe drinking water; sanitation; and pollution. Most of these come under the responsibility of local bodies.

• There is no provision in the Bill for the accreditation or for the regulation of teachers at medical colleges, nursing homes, hospitals, clinics, pharmacy and chemists.

Lack of govt. supports

• The bill fails to understand, that in certain cases, the doctors are compelled to charge high to recover the investment in the equipment’s that have to be imported.

• Even the diagnostic kits used in healthcare are made outside India, including in China. This eventually translates into a high Out of pocket expenditure by the patient

Lack of favorable research

environment

• Currently, it is found that in most of the cases, the faculty members are unable to do research as they are engaged in other hospital work to tackle patient load and do not have a proper support system from the institutions wherein they teach.

Regulatory capture by

private players

• Two-thirds of the members in the NMC will be medical practitioners. This will continue the influence of medical practitioners in regulating medical education and practice.

• This may derail the actual plans of the Government to form an independent and impartial regulator

Political interference

• 20 officials out of total 25 running the commission will be selected by the government.

• This will lead to undue interference by the bureaucracy in the medical and health sector

40% criteria

inadequate for

survival

• The NMC allows capping the fees on 40% seats of private colleges. Private institutions claim that this is far below the minimum threshold requirement for the private colleges to survive on their own.

Grievance redressal

• In cases of professional or ethical misconduct by medical practitioners, the practitioners can appeal a decision of the NMC to the central government.

• It is unclear why the central government, and not a judicial body, is the appellate authority.

ED CLASS 2 LUKMAAN IAS

CSE 2019 17

Licensing • There is no requirement for periodic renewal of the license to practice.

• Some countries including USA and UK require periodic testing to ensure that practitioners remain up to date

Compatibility • The Bill proposes a bridge course for practitioners of AYUSH to enable them to prescribe modern medicines.

• This step is considered to be harmful for the independent development of AYUSH.

Affordability and access

• Since the fees for the rest 60% of seats call be managed internally, this will fall upon the consumers and manifest in the form of out of pocket expenditure

Position without

responsibility

• The accreditation board is only advisory in nature. It lacks the teeth to enforce compliance of quality benchmarks by itself.

Overrides federal

structure

• Health is a part of state list. The bill does not mention anything about the representation from the states and Union Territories (UTs) to articulate the national agenda for medical education.

Conflict of interest

• All members of the accreditation board are supposed to be ex-officio members of the advisory board. This defies the concept of checks and balances

REPORTS OF THE PARLIAMENTARY STANDING COMMITTEE 2018

Emphasis on merit The committee proposed to provide a statutory basis for common entrance examination for admissions in medical courses and practice after completion of the same.

The committee strongly recommended deleting a provision from the Bill that gives discretionary powers to the Central govt. to allow those who have failed in the licentiate exam to practice medicine or perform surgery.

Improve teaching It advises the PG sub-board under accreditation board to accredit schools based on the contributions in research by their faculty members.

Respect federalism It mentions that the NMC should have an optimum representation from the states and UT in designing the curriculum.

Ranking of colleges The committee has proposed periodic publication of ratings of medical institutions.

Continuing the regulation of fees

structure

It empowers NMC to fix norms for regulating fees for a proportion of seats (at least 50% compared to 40% in the bill) in private medical colleges while allowing freedom to the promoters to manage the rest in a transparent way.

STAND OF NITI AAYOG ON ALLOWING PRIVATE PLAYERS

• It is argued that the provision of allowing private medical colleges to set the fees on 60% of the seats will make medical education inaccessible to India’s poor.

ED CLASS 2 LUKMAAN IAS

CSE 2019 18

• NITI Aayog claims that these fears are baseless as the current bill will create a fertile ground for the entry of new private colleges. Over a period of time, when their numbers will increase, this will help to foster a healthy competition among them that will eventually limit their ability to arbitrarily raise their fees.

WAY FORWARD:

Reduce Out of Pocket

Expenditure

Nearly 70% of patients in India suffer from NCD (Non-Communicable

Diseases). Way forward should be a cumulative effort involving promotive

(for example yoga), preventive and curative health.

Involve states There is a great deal of variation in the quality of state medical councils

across states. Efforts should be made to standardize the medical education

and practice and promote competitive federalism.

Reduce urban-rural

divide

India is a signatory of Alma Ata declaration. Hence it needs to create

strong provisions for the delivery of primary health care and achieve SDG

2030 goals.

Reduce potential

chances of conflict of

interest

The credentials of all office-bearers and members of the MCI must be

impeccable and open to public scrutiny.

All proceedings of the NMC must be open to public scrutiny.

CASE STUDY OF THAILAND

a) In the year 1972, Thailand came out with a policy that mandates three years of government

work for all post-graduates.

b) The first year is spent in provincial hospitals, while the second and third years are spent in

rural or community hospitals.

c) Statistical evidence indicates that this policy limited brain drains, and reduced medical

professional density disparity between rural and urban areas.

d) Kerala has also implemented compulsory rural service for all MBBS and PG doctors studying

in government medical colleges as a part of Arogyakeralam, its version of the National Rural

Health Mission.

e) This theme was also reverberated in the ‘The National Commission for Human Resources for

Health Bill (2011) wherein graduates from public funded institutions had to compulsorily

endeavour to serve in India for atleast three years

CONCLUSION:

Currently it appears that reforming MCI has become an end in itself while it should serve as a means

to attain the goals of improving health sector. For this, the government needs a comprehensive

approach that spans all the issues that impact the same.