Govt prepares ambitious move to remove bottlenecks in medical education and prepare more doctors to meet the demand
Pankaj Kumar | September 19, 2016
India faces an unenviable challenge of tackling the dual burden of diseases and lack of qualified health personnel. The number of surgeons, anaesthetists and obstetricians per hundred thousand people in India is 6.4 – compared to 59.2 in Brazil.
A 2015 PricewaterhouseCoopers report estimates that we are short of 3 million doctors and 6 million nurses. The rate at which we are currently producing doctors, it would take about 50 years just to clear the backlog. India simply cannot afford to wait another generation to address this shortage.
Why the situation has come to such a pass
One reason has been the inability of the central and state governments in investing in rapid expansion of medical education in tune with the country’s requirements. The gap could have been filled through private investments but the intrusive, non-transparent, infrastructure obsessed and unpredictable regulatory regime put in place by the Medical Council of India (MCI) has ensured that we can address neither the issue of the quantity nor of the quality of medical professionals churned out by our medical education system.
Such has been the mishandling of the sector by the MCI that there has been a rare unanimity of opinion in all the three pillars of democracy – the legislature, executive and judiciary – on the need to reform this sector by weeding out MCI.
The parliamentary standing committee on health in its 92nd report observed that the MCI “has repeatedly failed all its mandates over the decades” and urged the centre to usher in game-changing reforms.
Such is the distrust of the opaque functioning of the MCI that the supreme court was constrained to appoint an oversight committee headed by an ex-CJI, justice RM Lodha, to supervise the functioning of MCI till the time a decision on reforms is taken up by the appropriate executive or legislative authority.
The NDA government set up an expert committee under the late Ranjit Roy Chaudhury in February 2015. The committee had laid down the blueprint for reforms which forms the basis of the current draft National Medical Commission (NMC) Bill that is available on NITI Aayog website for public consultation, suggestions and feedback. The major features of the proposed NMC Bill are:
(1) The current system of elected regulators to be replaced by nominated regulators along with some representation of non-medical experts
(2) Separation of functions (undergraduate education, post-graduate education, assessment & rating and registration & ethics) into autonomous boards with overarching NMC for policy coordination
(3) A compact executive body (NMC) to facilitate quick decision-making
(4) NMC autonomous from the centre; vested with power to make regulations without referring it to the government
(5) Merit-based admissions through a compulsory common entrance examination (national eligibility cum entrance test – NEET) to stamp out the pernicious practice of discretion-based admission via the backdoor management/NRI quotas and/or capitation fees
(6) Ensure uniform standards of medical professionals graduating from different medical institutions through a mandatory national common licentiate examination conducted by the NMC which would be pre-requisite for grant of licence to practise and for registration as a medical practitioner. This outcome-based regulation would ab-initio (‘from the beginning’) curb opportunities for rent-seeking that are inherent in the input-based regulation model of the MCI
(7) Transparent and pro-active disclosure by the medical institution with regard to fees, facilities, faculty and infrastructure. A mandatory assessment and rating of medical colleges on annual basis to be carried out and published in order to enable prospective students to make an informed choice
Apart from the outright and understandable rejection by the MCI which has stubbornly opposed any attempt at reforms, the draft bill has been criticised by some others. Here we collect the major allegations and spoke with Niti Aayog sources for their counterarguments:
Allegation 1: The proposed NMC is undemocratic as it does away with the concept of elected regulators who constitute a majority at MCI
Counterargument: Regulated bodies electing their own regulator is a clear conflict of interest. Can we countenance a scenario where we permit telecom companies to elect the TRAI chief?
Allegation 2: Bringing non-medicos into NMC is an attempt at denying doctors the privilege of self-regulation in contrast with similar professional bodies such as the Bar Council of India (BCI) and Institute of Chartered Accountants of India (ICAI).
Counterargument: To cite an example closer to the domain, in the General Medical Council (GMC), the counterpart of MCI in the UK – all members are appointed by the government. Half of the GMC’s 12 members are doctors and the other six are non-doctor members. Health is too important a subject to be left to the doctors alone. Citizens must have a vital stake in the way the profession is conducted. The Medical Advisory Council – the overarching body which seeks to give representation to the states as an equal partner in setting the agenda for medical education and health – consists of 37 doctors out of total 46 members. In the NMC of 20 members, 11 are doctors, with key executive decision-making positions being reserved for the doctors. It would therefore appear that apprehensions of dilution of the role of doctors in the new regulatory body is entirely misconceived and misinformed. What is being sought to be achieved is that regulation is being rescued from the exclusive control of doctors.
“There is vested interest working against the bill as it is going to break their hegemony,” said the former MCI official.
Allegation 3: The third and most seemingly potent critique of the bill has been that it ostensibly seeks to promote the commercialisation of medical education. That private medical education in India has so far been beset by corruption and malpractice, and Niti Aayog’s proposal is simply to privatise medical education even further. High fees being paid by medical professionals for their training would ipso facto translate into magnifying the ills of unethical practices as they seek to recover their educational investments. This will be detrimental to the interests of the citizens because they stand to bear the brunt of medical malpractices both financially as well as in health terms. Regulation of fees of private unaided educational institutions has been a vexed legal issue. Through a series of judgments, from Unnikrishnan (1993), TMA Pai (2002), Islamic Academy (2005) and PA Inamdar (2007), the supreme court while recognising the right of such institutions to prescribe its own fee structure has subjected it to the limitation being non-exploitative with express ban on profiteering or capitation, with admission strictly based on merit. It has set up two committees chaired by retired high court judges in each state to monitor the admission procedure and the reasonableness of fee being charged as a temporary measure till the government legislates on this subject.
Counterargument: Despite the noble intent of the SC, what has been the outcome of the 23-year effort of such a Control Raj? The exploitation of students continues unabated; except that such transactions have merely been driven underground. The recent arrest of the Chancellor of SRM University for defrauding gullible students to the tune of Rs 75 crore is an apt illustration of this widespread malady. Thus, the real underlying issue that we need to consider is that currently we have 11 lakh students chasing about 55,000 MBBS seats. This artificially enforced scarcity provides unprecedented leverage to the unscrupulous promoters of the medical Institutions. This is worsened by the regulatory barriers to entry of right kind of promoters by the MCI and a discretionary admissions policy in the pre-NEET period.
It is our considered view that upon a realistic assessment of the existing state of regulatory capacity, it would be wiser to have lower entry barriers, monitoring of outcomes, and transparent, but autonomously determined, fee structure by the Institutions rather than perpetuating an ineffectively enforced Control Raj. It would be naïve to presume that the only or even the predominant source of ethical devaluation in the medical profession is caused by the declared component of the fees paid in obtaining education. It would also be simplistic to assume that one bill will be able to sort out the multiple problems plaguing the healthcare sector. A large number of reformative steps need to be taken; but as the Chinese proverb goes – a journey of a thousand miles begins with the first step. The NMC bill purports to be only that – a first step.
The MCI provides for an extremely unsound arrangement which officially institutionalises the regulation of those being regulated by themselves – doctors in this case. This introduces a fundamental conflict of interest with citizens having no voice on a service which is of vital importance to them. Further, the inspection-led instrument of regulation by the MCI depends upon controlling prices, inputs and processes. In such an institutional arrangement, it is no surprise that expansion of ‘private’ education would lead to unscrupulous colleges that charge ‘under the table’ fees, treat fake patients, and get away with it by bribing inspectors and regulators. It is alleged that NITI Aayog is simply recommending an expansion of ‘for-profit’ private education without considering the factors that have led to corruption, when, in fact, nothing could be further from the truth. This argument is akin to saying that since India’s ‘private’ firms were inefficient and produced poor quality goods before 1991, reforms to remove production licensing and allow an increase in the number of ‘private’ firms would just lead to more inefficiency and worse quality goods.
Niti Aayog is actually recommending a complete institutional overhaul that resolves the conflict of interest by introducing independence of regulation from those regulated. It is also recommending a shift away from input- and inspection-based regulation, which are factors that make corruption easy, to outcome-based regulation through a licensing exam for doctors, which makes corruption difficult (with the caveat that outcomes are measured correctly).
Why ‘for-profit’ appears bad word for some
Why it is difficult to understand that people will generally expect a return for providing such a difficult, time consuming and expensive service as medical education. Allowing ‘for-profit’ institutions along with transparently advertised fee structure permits honest promoters who want to be above board also to provide this service. The ability of people, and not just inspectors, to see which institution provides quality education and which does not (through outcome measures) will weed out the bad from the good over time.
Allegation 4: Expanding medical education will not automatically address the shortage of doctors in India’s public health systems. It is foolhardy to expect privately trained doctors to serve in the public health system.
Counterargument: Over 50 percent of AIIMS trained doctors have emigrated from India. Surely, then, it is just as foolhardy to expect publicly trained doctors to serve in the public health system or even in India, after having spent our tax money on them to boot.
The point is that India does not have a shortage of doctors only in the public health system. Compared to almost any international benchmark, we have an overall shortage of doctors and medical specialists. The role of regulation of medical education is to address this larger shortage of doctors in the country. Addressing the shortage within the public health system is the role of the executive branch in the states and at the centre. One evidence-backed way of doing this is to train public and primary health specialists with three-year degrees who can then be hired in the public health system. Chhattisgarh did exactly this, and a John Hopkins-PHFI study found that these specialists were just as effective as doctors in addressing the most common problems that come to a rural primary health centre. The promising programme, however, was shut down. Why? Because MBBS doctors felt threatened and since they were in charge of regulating medical education through the MCI, there was no chance that the course would be recognised. This is exactly the kind of situation that NITI Aayog’s proposed reform wishes to solve.
The pace of expansion of medical education in the government sector has not been commensurate with the growing health needs of the population. We therefore have a severe shortage of seats for medical education. We have an estimated 55,000 seats for MBBS. By comparison, we have 1.7 million seats for engineering courses (almost 30 times the number of seats in medicine). As a result, capitation which was as rampant in engineering is almost a thing of the past in the engineering education sector and promoters are finding it hard to attract students even after offering huge discounts in fees and many seats go vacant. This has been possible primarily because of the rapid expansion in supply, mostly by private education providers. Admittedly, the rapid expansion in colleges has not translated automatically into quality and those institutions that did not invest in quality have now closed down or are facing closure. And we need to keep this in mind while reducing regulatory barriers for entry of new medical colleges; but the premise that freedom to decide fee structure and allowing for profit institutions will lead to rampant unethical practices is a flawed one. The exit licentiate exam is indeed an instrument and moving to accreditation based regulatory regime is likely to give an impetus to quality while avoiding obstructions to setting up of new institutions.
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