[op-ed snap] National Medical Commission is no cure-all, many important questions remain

Context

Whether the National Medical Commission Bill passed by Rajya Sabha addresses the concerns in medical education.

Why medical education needs regulation

• to ensure that doctors are appropriately trained and skilled to address the prevailing disease burden
• to ensure that medical graduates reflect a uniform standard of competence and skills
• to ensure that only those with basic knowledge of science and aptitude for the profession get in
• to ensure ethical practice in the interest of the patients
• to create an environment that enables innovation and research
• to check the corrosive impact of the process of commercialization on values and corrupt practices
• The problem of inappropriately trained doctors of varying quality has been known for decades. The report of the Mudaliar Committee set up in 1959 pointed out how doctors had neither the skills nor the knowledge to handle primary care and infectious diseases that were a high priority concern then as now
• standards vary greatly with competence levels dependent upon the college of instruction

Importance of NMC

• In professionalising the MCI, with experts for all levels of education and practice
• In setting curricula, teaching content, adding new courses and providing the much needed multi sectoral perspectives
• It has the potential to link the disease burden and the specialties being produced. In the UK, it is the government that lays down how many specialists of which discipline needs to be produced, which the British Medical Council then adheres to. In India, the MCI has so far been operating independently. This gap can be bridged by the NMC
• It can encourage and incentivise innovation and promote research by laying down rules that make research a prerequisite in medical colleges
• MCI required a college to be inspected 25 times to get final recognition, each being a rent-seeking exercise. That “inspector Raj” will be done away with
• The excessive reliance on diagnostic tests is reflective of both commercial considerations as well as weak knowledge. Students spending lakhs to become doctors resort to unethical practices to recoup their investment and pollute the system. In the US, despite tight regulations and remunerative payment systems, there is still substantial unethical practice.

Limitations of the bill

1. Not enough to curb unethical practice and commercialisation of medical education. Today, there are 536 medical colleges with 79,627 seats. Of them, 260 or 48.5% are private with 38,000 seats. The bill allows differential pricing with freedom for the college managements to levy market determined fees on 19,000 students under the management quota. This is admission for those with the ability to pay. 
2. Bill has proposed mandating the NEET and NEXT. NEET was mooted for three reasons: 
   1. to reduce the pain of students taking almost 25 examinations to gain admission in a college
   2. given the abysmal level of high school education, to ensure a minimum level of knowledge in science
   3. to reduce corruption by restricting student admission to those qualifying the NEET.
   4. NEXT is an idea borrowed from the UK that has been struggling to introduce it. In all such countries, the licensing exams are stretched into modules, not a multiple choice questions type of exam. Bill has virtually given up inspections for assuring the quality of education.
3. Relying only on the NEXT as the principal substitute is to abdicate governance. Undoubtedly, there are grey areas giving scope for corrupt practices and production of substandard doctors.
4.  The reduced oversight allowing extensive discretionary powers to government makes it virtually an advisory body
5. permitting a registered medical practitioner to prescribe medicines
6. While there is a need to decentralize, to give to non-medical personnel some powers and authority, it needs tight regulation and supervision
7. continuance of the two parallel streams of producing specialists. By not bringing the DNB under the purview of the NMC, the DNB system is left open to abuse

Conclusion

Government has, under this Bill, arrogated to itself an unprecedented power to appoint people in the various arms of the proposed structure. The quality and integrity of these people will then define the future of the health system in India