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 Part-II of the series. You can read Part-I of the series here.
While there are many areas of concern in the proposed National Medical Commission (NMC) Bill, 2017, like the National Exit Test (NEXT) — an exit-cum-licensure exam, and the ability of the private medical colleges to charge as they wish for 60% of their seats, the most troubling of them are the clauses which approve a “bridge course” for practitioners of Ayurveda and Homeopathy to prescribe mainstream medicines like an MBBS graduate can.
In Section 49(4), the bill says that a "specific bridge course that may be introduced for the practitioners of Homoeopathy and of Indian systems of Medicine to enable them to prescribe such modern medicines at such level as may be prescribed”, whereas, Section 54(o) of the bill adds that the government can notify rules for “the modern medicines that the practitioners of homeopathy and of Indian medicine may prescribe”. These are problematic sections.
Then there is also the possibility of the new NMC bill abolishing Section 15 of the Indian Medical Council Act, which says that the basic qualification to practise modern medicine is MBBS, thus throwing open the doors for all types of alternative medicine practitioners from plying their trade in the mainstream and prescribing modern drugs without any fear of punishment.
The excuse from the government, of course, is that the primary health sector in rural areas are under-served and hence they are trying to involve people from alternative medical streams in healthcare of the masses (something like the ridiculous “child-doctors” being tried in Gujarat to address the shortage of doctors in schools).
For decades, successive governments have turned a blind eye towards alternative medical practitioners prescribing modern medicines, and sometimes even dangerous medicines in the guise of alternative medicine. This new law legitimises the practice and makes it mainstream.
It is a very sore point — how can a bridge course replace the training provided by an MBBS degree? How can you squeeze in five-and-a-half years of modern medicine into a six-month bridge course? This move is only a way to shortcut to fill gaps in healthcare without spending any money to improve medical education in India. Even if the argument is that this "bridge course for AYUSH doctors" will serve the rural areas, why should rural areas deserve poorly trained AYUSH practitioners prescribing modern medicines, which is not part of their course curriculum?
It is both unethical and devious for the government to even suggest. The bridge course is thus an ill-thought-out idea.
Are the politicians, who are proposing this bill, ready to have their families being treated only by these type of “bridge course-educated AYUSH doctors”? I’m guessing the answer is no!
A 2015 report by Reuters, has some worrying statistics regarding the quality of existing medical professionals and the sorry state of healthcare in India.
"About 45 percent of the people in India, who practice medicine have no formal training, according to the Indian Medical Association. These 700,000 unqualified doctors have been found practising at some of India’s biggest hospitals, giving diagnoses, prescribing medicines and even conducting surgery," it says.
The article cited an interview by Balwant Arora, a Delhi resident in his 90s, wherein he said that he issued "more than 50,000 fake medical degrees from his home until his forgery ring was broken up by the police in 2011". Each buyer, the article adds, "paid about $100 for a degree from fictitious colleges".
“There is a shortage of doctors in India. I am just helping people with some medical experience get jobs,’’ said Arora, who was twice convicted and jailed for forgery. “I haven’t done anything wrong,” Reuters quoted him as saying.
The report also says, "India currently has about 840,000 doctors – or about seven physicians for every 10,000 people. That compares with about 25 in the United States and 32 in Europe, according to the World Health Organisation. The shortfall has persisted despite India having the most medical schools of any nation. That’s because the size of graduating classes is small – typically 100 to 150 students."
The government is now taking the role of the Balwant Aroras by legitimising this quackery. How different is the government as compared to these frauds issuing fake medical degrees? Soon there will be a demand for bridge courses for post-graduate and sub-speciality training as well.
On the one hand, the NMC Bill proposes an exit licensure-cum-PG entrance exam like NEXT to weed out poorly trained doctors from sub-standard medical colleges, but on the other hand, it introduces a bridge course for AYUSH practitioners to prescribe modern medicine. The NMC contradicts its own stated objectives!
What a medical regulatory body and the government actually needs to do?
I. Healthcare reform: There is no question that the Indian healthcare industry needs an overhaul, and major reforms in the medical sector are the need for the hour, but just replacing a medical regulation body of doctors with several bureaucrats and government-sponsored sycophants will not solve the real problems plaguing the system. India needs oversight, punitive punishments including long jail terms for the corrupt in this system.
India doesn’t need a new medical regulatory system by purging doctors from it; India needs a system which rewards good work while severely punishing corruption and incompetence.
II. Recruiting doctors for primary care: The recruitment for public healthcare centres (PHCs) is done via the state public service commissions (SPSCs). What is often seen in most states is that many of the vacancies are not filled and it is not due to lack of applications but due to the high level of corruption that is present in the recruitment process. One has to pay a ridiculous amount of money as bribes to be recruited into government services or have connections of politicians to gain entry. There needs to be a transparency in the selection process as well as curbing of corruption among the officials by taking severe action on them.
III. Empowering MBBS graduates: An MBBS graduate needs to be further trained in specific areas like obstetrics and gynaecology, paediatrics, general surgery, orthopaedics so that he or she can take up more responsibility in primary care like conducting deliveries, medical termination of pregnancies, treating malnutrition and conducting immunisation drives, draining abscesses and minor surgical procedures, setting fractures with casts, running government health programmes, etc. If adequate infrastructure is provided in rural areas, there is no reason why MBBS graduates will not go to rural areas.
IV. Medical assistants: India does need to recognise the need for integration of a large volume of practitioners of Indian systems (who have been operating illegally till date) into mainstream medical care. This can be done by designing a separate course of two-three years (and not a bridge course) to create a separate class of medical workers called medical assistants (not doctors or physicians). Nurses, practitioners of alternative medicine, midwives and optometrists can apply for this course to become medical assistants. The dispensing of over the counter (OTC) drugs, giving vaccines including injections, dispensing drugs and dietary supplements supplied by government schemes, providing appropriate dietary advice can be in the realm of their duties. However, they should 'not' be able to practice modern medicine on par with an MBBS practitioner. For example, once a patient is diagnosed with tuberculosis and prescribed a DOTS regimen (a government-sponsored scheme), the patient's further treatment can be supervised by medical assistants and referred to higher centres in case of complications of the disease or drugs.
V. Modern and alternative medicine should remain different: The government needs to keep the evidence-based scientific modern medicine separate from pseudo-scientific alternative streams of medicines based on herbal concoctions and water memory. An integration of science and pseudo-science is impossible. One cannot have practitioners of one stream prescribe medicines of another stream without training for it comprehensively. Ayurveda and Homeopathy are called "alternative medicine" for a reason.
VI. Help develop scientific temper: The government should not promote pseudo-science among the public. The Indian public should develop a sound scientific temper and not be victims of propaganda in the name of nationalism associated with Indian systems of medicine.
The NMC Bill in its present form doesn’t address any of the above issues. It focusses on plugging the holes by lowering the standards rather than reforming the system itself. The quality of medical professionals is more important than just pure numbers and the government would do well to recognise that. There has to be a political will in the correct direction and the public needs to ask the government the right questions.
Leading cardiac surgeon Dr Devi Shetty, in an interview, told the The Indian Express that to get the right answers from the government, the public should be asking the right questions. "Why should a pregnant woman die during childbirth every 12 minutes; why do three lakh children die the day they are born? Why do 1.2 million children die before celebrating their first birthday? It is unacceptable."
Shetty states that India undergoes nearly 5.2 million Caesarean sections per year. But India doesn't have the necessary medical professionals required to conduct these many C-sections. "In such a situation how do you expect the maternal mortality rate to come down?" he asks.
The health of the nation is dependent on the health of the medical sector of the country. The question we all should be asking is: why is the health of the nation being trivialised by unhelpful government actions?
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Updated Date: Jan 12, 2018 14:45:51 IST