Editor's Note: With the contentious National Medical Commission (NMC) Bill 2017 sent to the Standing Committee for review, an Ophthalmic Plastic Surgery consultant takes a deeper look at the bill and how it measures up in terms of solving major issues plaguing the medical education and healthcare industry in India. This is the first of a two-part series.
“Quis custodiet ipsos custodes?”
"Who will guard the guards themselves?"
— Roman poet Juvenal (Satires).
In 2015, the NITI Aayog was tasked to recommend reforms in the medical sector plagued by corruption within Medical Council of India (MCI). A three-member NITI Aayog panel came up with recommendations to reform the health sector. This cleared the way for a bill specifying MCI's closure and creation of the National Medical Commission (NMC) in its place. The doctors and people in the medical field (by far one of the biggest stakeholders in this sector) were excluded from being part of this supposed "reform" process.
MCI is an elected statutory body comprising mostly of qualified medical doctors and some government nominated ex-officio members to help in the functioning of the organisation. MCI is responsible for maintaining uniform standards of medical education in both undergraduate and postgraduate medical courses. They are responsible for recognition or de-recognition of medical qualifications awarded by medical institutions of India or foreign countries. They also maintain the national registry for permanent registration/provisional registration of doctors with recognised medical qualifications. They also work with foreign countries on the matter of mutual recognition of medical qualifications. The MCI along with state medical councils regulates medical education by setting curriculum, safeguarding the rights of the patients and taking action on medical negligence.
The MCI has not really been smelling of roses in recent years with a slew of corruption charges eroding the trust that should be placed on such an institution. Even after Ketan Desai’s arrest in 2010 and dissolution of the MCI, the rot in the system has not been completely uprooted. The fraud runs both ways — the MCI and the medical institutions were hand-in-glove in this racket. A 2015 extensive report by Reuters paints a very poor picture of the medical education scene in the country. An edited excerpt from the article below:
"Government records show that since 2010, at least 69 Indian medical colleges and teaching hospitals have been accused of such transgressions or other significant failings, including rigging entrance exams or accepting bribes to admit students. Two dozen of schools has been recommended for outright closure by the regulator. Patients pretending, they are sick and doctors posing as faculty members are routine. The ramifications of India’s broken medical-education system are being felt beyond the country’s borders."
The training in many new medical colleges (both government and private) are sub-par and can often be bought for a price in private medical colleges. We do have a shortage of doctors in India, but lowering the standards of training is a recipe for disaster. Poorly trained doctors can do more harm than having a shortage of doctors. We do not have the necessary infrastructure to train enough doctors to meet the demand that exists in India. These unscrupulous private medical colleges become hotbeds of corruption in healthcare where the health of the country is sold off to the highest bidder.
There is massive fraud occurring in the medical education sector today — the MCI and governments are to be squarely blamed for this mess. The NMC Bill, 2017, is not the right way to address this problem. Instead of cleaning up the system, the NMC Bill adds more red tape into the system.
Replacing a democratic institution with a government controlled body
The NMC Bill seeks to replace a self-regulatory, elected federal structure like MCI with a commission whose members will mostly be bureaucrats, social activists and other professional “experts” from civil society like chartered accountants, engineers, lawyers, management professionals, etc. While a professional body being regulated by people from outside the profession seems like a laughable proposition, that it is happening in healthcare is a worrying shift indeed.
Would you have doctors and engineers regulating chartered accountancy in India? Would you have politicians, bureaucrats and management professionals heading the Bar Council of India? The NMC Bill is as ludicrous as that.
The problem with the MCI was corruption and not that it was run by doctors. Corruption inside the MCI went unpunished for long. The NMC Bill does not address this problem. Are we to believe that the non-doctors will be less corrupt than the earlier corrupt MCI mandarins?
The table below gives the hierarchical structure of the NMC:
The above table shows just how much control the government gets over the medical sector as per the NMC Bill. Governments should not decide on the complete composition of any professional medical regulatory body as they have conflicts of interest — either with their politicians owning medical colleges or due to vote bank politics. Governments cannot run a professional body, much less a medical regulatory body because then the government runs the risk of using medicine to accomplish its political goals rather than public needs.
Majority of the medical colleges — private and government — established in the last decade or so have failed on the basic metrics of imparting modern medical education and training. With the NMC, the government is making it easier to establish such medical colleges without the risk of closure once approved even if they have a sub-standard infrastructure. The NMC bill proposes to remove the clause de-recognising medical colleges if found not following norms, and substituting that punishment with fines.
Also, the new Bill allows medical colleges to increase the number of seats in undergraduate courses and start post-graduate courses without seeking permission from the central regulatory body. This will encourage an indiscriminate free-for-all increase in MBBS seats and residency programmes without a parallel improvement in infrastructure and quality of the programmes. To provide context, MCI has refused recognition for 132 medical colleges in the last year out of which 97 belonged to politicians. The applications for new medical colleges were rejected for sub-standard faculty and infrastructure. How will the NMC with members nominated by the government reject recognition of such sub-standard medical colleges? This is a direct conflict of interest and the NMC fails to be an independent regulatory authority that it is supposed to be.
Moreover, how does the government plan to check on the corruption inside NMC? What are the measures to prevent NMC from becoming another corrupt MCI? The National Advisory Council (NAC) which was supposed to oversee NMC has members from the NMC as well. This again gives very little confidence that the new NMC will not become corrupt as the NAC is hardly an independent body. How is the new NMC any different from the previous MCI other than the lack of doctors in the new one?
Basically, the question is who will guard the guards?
The Lok Sabha has sent the NMC Bill to the standing committee to relook the controversial parts of the Bill. The committee will do well to think this through properly before going down the road of no return. The standards for medical education should be uniform for private and government colleges. These standards should be established keeping all the stakeholders into confidence — the doctors, the civil society organisations and the government. The government needs to incentivise primary care for new MBBS graduates by providing a good career trajectory, basic but robust infrastructure and decent remuneration. Lastly, the government needs to spend more than the dismal 1.3 percent of the GDP on healthcare and medical education and only then will they see any change on the ground.
In an interview to the Indian press in 2015, Richard Horton, editor of the prestigious British medical journal, Lancet, said this about India’s healthcare:
“India is on the edge and it can take two routes. It can take a route of investing in health and investing in its people and creating a thriving and flourishing future for India…or, it can do what it is doing now and ignore health in which case it will see epidemics sweep across the country creating an unsustainable future and destroying national security. India needs to make a choice. Should we commit to stand with Myanmar, Sierra Leone, and Haiti and neglect public services or emulate the experiences of better-performing health systems in Europe, Thailand, and Cuba, who have invested in building public services?”
Updated Date: Jan 06, 2018 14:39 PM