Medical Education Governance in India

Medical Education Governance in India

[op-ed snap] Back to the blackboardop-ed snap

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Nothing much

Mains level : NEET - findings and need to reorient


Context

Recent data from Tamil Nadu that became available through the Madras High Court showed a clear link between coaching classes and securing a medical seat. This is a worrisome situation. 

Data

    • As per data submitted to the Madras High Court by the government of Tamil Nadu, the bulk of the students who secured MBBS seats in the State in 2019 had taken coaching classes to prepare for the exam. 
    • Only 1.6 % of all students who joined the government medical colleges had managed to get a seat without undergoing any preparatory coaching program. 
    • Even in private medical colleges, only a marginally higher – 3.2% had got through without coaching classes. 
    • Data also showed that a significant percentage of students in both government (66.2) and private colleges (64.4) had to take multiple attempts at NEET to score a seat. 
    • The costs of coaching classes are huge and run into lakhs of rupees. It clearly puts medical education out of the reach of the poorer sections.

Opposition to NEET by TN

    • Cost – prohibitive cost factor has been in the list of arguments against NEET right from the beginning. 
    • Out of reach to many – It would keep a segment of students out of the race was the point posited by the State, citing the example set by the IIT-Joint Entrance Examination. 
    • Marginalised groups – coaching classes would determine entry to courses and put out of the race, students who were poor, or hailed from rural areas. 
    • Quality of education – the shortcoming in this sector makes expensive coaching classes the norm. 
    • State of classrooms – reports such as the ASER have revealed sad neglect of a key nation-building function — school education. 

Way ahead

    • Ensuring that quality education is imparted at schools by well-trained teachers would obviate the need for coaching outside of classes. 
    • NEET hopes to choose the best students for a career in medicine and remains value-neutral in every other way. 
    • States should put in place a series of steps that would make learning meaningful and fun for children, and in the interim, provide free NEET coaching classes to help disadvantaged students make that leap.
Medical Education Governance in India

[op-ed snap] Medical devices are not drugsop-ed snap

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Nothing much

Mains level : Medical devices regulations in India


Context

The Ministry of Health and Family Welfare is going to put in place a regulatory framework for medical devices that will favor the lobbyists for the medical device industry. The medical industry has already proven itself to be brazenly irresponsible towards patients in India as we are seeing in the ongoing hip-implant scandal.

Steps towards regulation

  • Regulation, not law – Rather than moving a new law to regulate the medical device industry, the ministry is creating a regulatory framework out of notifications and rules, using powers delegated under the Drugs and Cosmetics Act, 1940.
  • The ministry notified the Medical Device Rules, 2017 using powers under the Drugs and Cosmetics Act. At that time, only a few medical devices were notified as “drugs”. 
  • In the latest notification, the government announced its intention to treat all medical devices as “drugs” under the Drugs and Cosmetics Act. All medical devices would be placed within the framework of the Medical Device Rules, 2017. 
  • Poor regulation – retrofitting medical devices into the Drugs and Cosmetics Act will lead to a toothless regulatory framework for devices, similar to what exists for drugs today.

Problems with the move

  • Bypassing parliament – The ministry cannot create new offenses or penalties through its rule-making authority. Only Parliament can enact a law that creates new offenses and penalties for wrongdoing. The Medical Device Rules 2017 contain no penal provisions. 
  • No legally binding provisions – Although the Drugs and Cosmetics Act contains a penal provision for the manufacture of substandard drugs, it cannot be used to penalise manufacturers of sub-standard medical devices. Legally binding standards recognised in the Second Schedule to the Drugs and Cosmetics Act covers only pharmacopeias for drugs. 
  • If no standards for medical devices are recognised in the Second Schedule, there can never be a prosecution of a manufacturer of sub-standard medical devices.
  • Foreign markets – Companies that make defective products will recall them from foreign markets and sell the same product in India, and comply with the law.  
  • Even though the sale of substandard drugs can be prosecuted under the current law, most manufacturers who make poor quality drugs go scot-free. 
  • No prosecutions will take place because there will be no basis to prosecute intentional wrongdoing in the law.
  • Standards of medical devices – Medical devices will be far more difficult to standardise when compared to drugs.
  • No tools – There are no tools available to Indian regulators under the proposed framework to hold makers of sub-standard medical device manufacturers to account. At most, the ministry can prohibit the manufacture and sale of certain medical devices under Section 26A or cancel a license to prevent future harm. 
  • Past errors – There are no penalties or prosecution to punish for the harm already inflicted on patients due to negligence or worse, intentional wrongdoing by the manufacturer.
  • Registry of patients – One of the main challenges faced by the government in securing justice for faulty hip-implants was to secure a list of patients who had received the implant through surgery.
  • Neither the doctors nor the hospitals have an incentive to share the list of patients or even inform the patients because it would mean opening themselves up to legal liability for surgically implanting faulty devices in the patient’s body.
  • The proposed regulatory framework will do little to hold the powerful medical devices industry accountable in cases of intentional wrongdoing. 
  • Medical devices are not drugs, and it would be a grave mistake to apply the same regulatory framework to regulate these complex devices.

Way ahead

  • Create a confidential patient register that should be maintained by the government to record all details of implants.
  • This register could be used to notify patients in the case of malfunctioning devices. 
  • The government must rethink this toothless framework and instead enact a new law through Parliament.
  • There is a need for new ideas to regulate this industry in the Indian context where the courts lack the capacity to tackle such complex issues.
Medical Education Governance in India

[op-ed snap] Writing out a clean Bill on healthop-ed snap

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Nothing much

Mains level : Analysis of NMC bill


CONTEXT

The last few days witnessed so many concerns being raised over a few clauses of the National Medical Commission (NMC) Bill. 

Concerns

There are five primary concerns:

  1. National Eligibility-cum-Entrance Test /National Exit Test
  2. Empowering of community health providers for limited practice
  3. Regulating fees for only 50% seats in private colleges
  4. Reducing the number of elected representatives in the Commission
  5. Overriding powers of the Centre.

Examinations

  1. For the past few years, a separate NEET is being conducted for undergraduate and postgraduate courses. In addition there are different examinations for AIIMS and JIPMER.
  2. This Act consolidates multiple exams at the undergraduate level with a single NEET and avoids multiple counselling processes.
  3. NEXT is the final year MBBS examination across India, an entrance test to the postgraduate level, and a licentiate exam before doctors can practise.
  4. It aims to reduce disparities in the skill sets of doctors graduating from different institutions. 
  5. Thus it implemented a ‘One-Nation-One-Exam’ in medical education.

Limited licence

  1. Though 70% of India’s population resides in rural areas, the ratio of doctors in urban and rural areas is 3.8:1. 27,000 doctors serve about 650,000 villages of the country.
  2. A recent study by the WHO shows that nearly 80% of allopathic doctors in rural areas are without medical qualification.
  3. NMC Act attempts to address this gap by effectively utilising modern medicine professionals, other than doctors in enabling primary and preventive health care. Evidence from China, Thailand and the United Kingdom shows such integration results in better health outcomes. Chhattisgarh and Assam have also experimented with community health workers. 

Fee structure

  1. Private medical colleges are capitation fee-driven and resort to a discretionary management quota and often have charges of corruption levelled against them.
  2. The Indian Medical Council Act, 1956 has no provision for fee regulation. 
  3. Until now, ‘not-for-profit’ organisations were permitted to set up medical colleges, involving enormous investments and a negotiation of cumbersome procedures.
  4. NMC Act removes the discretionary quota by using a transparent fee structure. It empowers the NMC to frame guidelines for determination of not only fees but all other charges in 50% of seats in private colleges to support poor and meritorious students.
  5. The Act also provides for rating of colleges. Reducing entry barriers for setting up medical colleges, along with their rating, is expected to benefit students.

Representation in the NMC

  1. The current electoral process of appointing regulators is saddled with compromises and attracts professionals who may not be best suited for the task at hand.
  2. Act provides for a transparent search and selection process with a mix of elected and nominated representatives, both in the search committee and the commission itself.
  3. The government added members from State medical councils and universities.
  4. Government should be able to give directions so that NMC regulations align with its policy.

Other features

  1. The Act establishes the Diplomate of National Board’s equivalence to NMC-recognised degrees.
  2. It also promotes medical pluralism.
  3. There is a paradigm shift in the regulatory philosophy from an input-based, entry barrier for education providers without corresponding benefits, to becoming outcome-focused. 
  4. Both the number of doctors and their skill sets are expected to improve. 
  5. Autonomy to boards and segregation of their functions will avoid a conflict of interest and reduce rent-seeking opportunities. 
  6. ‘Quacks’ are liable to face imprisonment or be fined or both.

Medical education needs continuous reforms in order to usher in improvements in health care. NMC Act is a serious attempt to meet the primary need of more medical professionals in the country.

Medical Education Governance in India

[op-ed snap] A second opinion on doctor accreditationop-ed snap

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Nothing much

Mains level : NMC Bill - analysis; Challenges with MCI


CONTEXT

National Medical Commission (NMC) Bill, 2019 passed by the Rajya Sabha evoked widespread protests from doctors. The Indian Medical Association (IMA) called an all-India strike against a few contentious aspects of the bill.

Contentious provision

  1. Section 32 of the NMC Bill would grant “limited” licenses to almost 3,50,000 “community health providers” to practice allopathic medicine, provided they meet a set of qualifying criteria.
  2. Practitioners of ayurveda, yoga and naturopathy, unani, siddha and homoeopathy could undertake a “bridge course” and legally start offering primary healthcare.

Reasons behind the provision

  1. India is woefully short of trained doctors, especially in the countryside.
  2. The shortage has slowed the state’s program to scale up healthcare facilities and medical education infrastructure.
  3. India still has less than one doctor for every 1,000 people, the WHO’s minimum ratio for healthcare adequacy.
  4. For the efficacy of schemes such as Ayushman Bharat covering 500 million citizens with health insurance—a vast leap needs to be taken on that count.
  5. These factors favor a pragmatic approach; a licensing system by which paramedics and others with an elementary grounding in healthcare could make up a part of the shortfall.
  6. Public services are unreliable and many find themselves priced out of the private market, thus, making medical consultancy unaffordable.

Problem 

  1. According to the IMA, letting patients be treated by people without MBBS degrees would amount to quackery gaining legitimacy in a country full of fraudulent cures and dodgy practices.

Way ahead

  1. Independent panel of well-regarded doctors could keep a close watch on the eligibility process for licenses.
  2. This could involve a common test after practical training has already been imparted.
Medical Education Governance in India

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

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Nothing much

Mains level : National Medical Commission Bill; Problems of MCI


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

Medical Education Governance in India

Explained: What changes are being brought in medical education?Explained

Note4Students

From UPSC perspective, the following things are important :

Prelims level : National Medical Commission (NMC)

Mains level : Read the attached story


Background

  • Union Health Minister has introduced the National Medical Commission (NMC) Bill in Lok Sabha.
  • An earlier version of this Bill was introduced in the 16th Lok Sabha, and had passed the scrutiny of the Parliamentary Standing Committee on Health and Family Welfare.
  • However, that Bill lapsed at the end of the term of the last Lok Sabha.
  • Once the NMC Bill is enacted, the Indian Medical Council Act, 1956, will stand repealed.
  • The existing Act provides for the Medical Council of India (MCI), the medical education regulator in India.

Why is Medical Council of India being replaced?

  • The Parliamentary Standing Committee on Health and Family Welfare examined the functioning of the MCI in its 92nd report (in 2016) and was scathing in its criticism.
  • The MCI when tested on the above touchstone (of producing competent doctors, ensure adherence to quality standards etc) has repeatedly been found short of fulfilling its mandated responsibilities.
  • Medical education and curricula are not integrated with the needs of our health system.
  • Many of the products coming out of medical colleges are ill-prepared to serve in poor resource settings like Primary Health Centre and even at the district level.
  • Medical graduates lack competence in performing basic health care tasks like conducting normal deliveries; instances of unethical practice continue to grow due to which respect for the profession has dwindled.

How will the proposed National Medical Commission (NMC) function?

  • The NMC Bill provides for the constitution of a 25-member NMC selected by a search committee, headed by the Cabinet Secretary, to replace the MCI.
  • The Bill provides for just one medical entrance test across the country, single exit exam (the final MBBS exam, which will work as a licentiate examination), a screening test for foreign medical graduates, and an entrance test for admission in postgraduate programmes.
  • The Bill proposes to regulate the fees and other charges of 50 per cent of the total seats in private medical colleges and deemed universities.

Medical Advisory Council

  • It will include one member representing each state and UT (vice-chancellors in both cases), chairman of the UGC, and the director of the National Accreditation and Assessment Council — will advise and make recommendations to the NMC.
  • Four boards — dealing with undergraduate and postgraduate medical education, medical assessment and rating board, and the ethics and medical registration board — will regulate the sector.
  • The structure is in accordance with the recommendations of the Group of Experts headed by Ranjit Roy Chaudhury set up by the Union Health Ministry to study the norms for the establishment of medical colleges.

Change in regulatory nature

  • The Bill marks a radical change in regulatory philosophy; under the NMC regime, medical colleges will need permission only once — for establishment and recognition.
  • There will be no need for annual renewal, and colleges would be free to increase the number of seats on their own, subject to the present cap of 250.
  • They would also be able start postgraduate courses on their own.
  • Fines for violations, however, are steep — 1.5 times to 10 times the total annual fee charged.

What are the changes in the 2019 Bill?

  • One, it has dropped a separate exit examination.
  • Two, it has dropped the provision that allowed practitioners of homoeopathy and Indian systems of medicine to prescribe allopathy medicines after a bridge course.

The National Exit Test (NEXT)

  • A single National Exit Test (NEXT) will be conducted across the country replacing the final year MBBS exam, and the scores used to allot PG seats as well.
  • It will allow medical graduates to start medical practice, seek admission to PG courses, and screen foreign medical graduates who want to practise in India.
Medical Education Governance in India

[op-ed snap] What’s NEXT?Mains Onlyop-ed snap

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Nothing Much

Mains level : NEXT and medical education in India


CONTEXT

In its second iteration, the National Medical Commission (NMC) Bill seems to have gained from its time in the bottle, like ageing wine. The new version has some sharp divergences from the original.

Background

  • Presented in Parliament in 2017, it proposed to replace the Medical Council Act, 1956, but it lapsed with the dissolution of the Lok Sabha.
  • The NMC will have authority over medical education — approvals for colleges, admissions, tests and fee-fixation.
  • The provisions of interest are in the core area of medical education. The Bill proposes to unify testing for exit from the MBBS course, and entry into postgraduate medical courses.
  • A single National Exit Test (NEXT) will be conducted across the country replacing the final year MBBS exam, and the scores used to allot PG seats as well.
  • It will allow medical graduates to start medical practice, seek admission to PG courses, and screen foreign medical graduates who want to practise in India.

Changes in National Exit Test (NEXT)

  • Per se, it offers a definite benefit for students who invest much time and energy in five years of training in classrooms, labs and the bedside, by reducing the number of tests they would have to take in case they aim to study further.
  • There are detractors, many of them from Tamil Nadu — which is still politically opposing the National Eligibility-cum-Entrance Test (NEET) — who believe that NEXT will undermine the federal system, and ask whether a test at the MBBS level would suffice as an entry criterion for PG courses.
  • The Bill has also removed the exemption hitherto given to Central institutions, the AIIMS and JIPMER, from NEET for admission to MBBS and allied courses.

Benefits

  • In doing so, the government has moved in the right direction, as there was resentment and a charge of elitism at the exclusion of some institutions from an exam that aimed at standardising testing for entry into MBBS.
  • The government also decided to scrap a proposal in the original Bill to conduct an additional licentiate exam that all medical graduates would have to take in order to practise, in the face of virulent opposition.
  • It also removed, rightly, a proposal in the older Bill for a bridge course for AYUSH practitioners to make a lateral entry into allopathy.

Way Forward

  • It is crucial now for the Centre to work amicably with States, and the Indian Medical Association, which is opposed to the Bill, taking them along to ease the process of implementation.
  • At any cost, it must avoid the creation of inflexible roadblocks as happened with NEET in some States.
  • The clearance of these hurdles, then, as recalled from experience, become fraught with legal and political battles, leaving behind much bitterness.
  • NEXT will have to be a lot neater.
Medical Education Governance in India

IMA moots ethics code overhaulDOMRPriority 1


Note4students

Mains Paper 4: Ethics | Public/Civil service values and Ethics in Public administration: Status and problems; ethical concerns and dilemmas in government and private institutions; laws, rules, regulations and conscience as sources of ethical guidance.

From UPSC perspective, the following things are important:

Prelims level: Not Much

Mains level: Reforms required in health sector


News

Ethical Studies for Doctors

  1. Can an individual doctor advertise, have a website to promote her practice to compete with aggressively marketed corporate hospitals?
  2. Should the donation of cadaver organs be made mandatory for all?
  3. Is it important for medical students to study ethics throughout the duration of the MBBS course?
  4. Marking a bold departure from the existing code of ethics that covers the medical profession, the IMA is in the process of redefining the code in order to ensure a much more contemporary outlook.

Redefining the Code of Medical Ethics

  1. The current code of medical ethics by the Medical Council of India dates back to 2002.
  2. Much has changed in the medical field since then and many relevant topics do not find a mention in the present code.
  3. IMA would be releasing a handbook on the redefined code of medical ethics.
  4. The handbook would comprise 24 topics that either need to be reviewed or find no mention in the current code.
  5. The code would subsequently be submitted to all the relevant Central Ministries – health, medical education, law and justice and the MCI – for consideration.

(A) For Advertisement

  1. The current MCI norms do not allow doctors to publicise their practice through any type of advertising.
  2. Big private hospitals are constantly promoting their set ups through advertisements in all mediums.
  3. Hence it is essential for individual doctors, especially those who have just begun practice, survive such competition.
  4. The IMA believes that any publicity material should be ethical and approved after scrutiny by the respective State medical councils.

(B) For Doctor-assisted Suicide

  1. Presently doctors cannot give consent for deciding on pulling the plug.
  2. This decision can only be taken by relatives.

(C) For ARTs

  1. Ethical issues around Assisted Reproductive Technology and surrogacy also find a mention in the handbook.
  2. The IMA states that doctors should ethically ensure that surrogates and egg donors are not exploited.

(D) For Organ Donation and Transplants

  1. The IMA also recommends that cadaver organ donations (from brain dead people) must be made compulsory for all unless an individual specifically states that he or she does not want to become an organ donor.
  2. Cadaver organ donations are currently carried out in India only when an individual has explicitly expressed a wish to donate or with the consent of immediate relatives in cases of brain death, creating a shortage of cadaver organs for transplants.
  3. India carries out a high number of living donor transplants as compared to cadaver organ donations.
  4. Presently we have a long waiting list of patients for organ transplants.
Medical Education Governance in India

[op-ed snap] Billed for change: NMC Billop-ed snap


Note4students

Mains Paper 2: Governance | Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

Prelims Level: Particulars of the NMC bill

Mains Level: Concerns discussed, regarding the NMC bill, in the newscard.


News

Acceptance of suggestions

  1. The Union Cabinet has recently approved six out of the dozens of changes to the contentious National Medical Commission (NMC) Bill that were suggested by a Parliamentary Standing Committee

These changes address some of the loudest criticisms of the Bill

  1. Among them, the final year MBBS exam is now merged with an exit exam for doctors,
  2. and a contentious bridge course for AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homeopathy) practitioners has been removed
  3. Health-care experts had recommended other modifications, which the Cabinet ignored
  4. For example, despite the Cabinet’s amendments, the NMC, the regulatory body that will replace the Medical Council of India, will be heavily controlled by the government

Other changes accepted by the cabinet

  1. The amendments cleared by the Cabinet also increase State representation in the NMC from three part-time members to six, in what seems like a gesture to please the States
  2. Contrast this with the parliamentary committee’s recommendation to include 10 State representatives, given India’s vastness
  3. Another amendment that doesn’t go far enough is the decision to raise the proportion of private college seats for which fees will be regulated from 40% to 50%
  4. The fees for unregulated seats could then increase abruptly, pushing poorer medical aspirants out of the system

Future challenges

  1. Despite these deficiencies, if passed by Parliament, the legislation will mark a new era for medical education in India
  2. The next step will be to design rules and regulations that capture the intent of this law(NMC bill)
  3. This itself will be a massive challenge
  4. Another concern is that under the new amendments States now have the freedom to implement an AYUSH bridge course, even if no longer mandatory
  5. How will the Centre ensure the quality of such courses to prevent a new set of poorly trained doctors from emerging?
Medical Education Governance in India

[op-ed snap] Is NEXT the panacea for medical education woes?op-ed snap


Note4students

Mains Paper 2: Governance | Issues relating to development & management of Social Sector/Services relating to Health, Education, Human Resources

From UPSC perspective, the following things are important:

Prelims level: Medical Council of India, National Medical Commission (NMC), National Exit Test (NEXT)

Mains level: Medical education system in India and related issues


Context

National Exit Test for medical students

  1. Union cabinet intends to replace the Medical Council of India with the National Medical Commission (NMC)
  2. It is also proposed  to have National Licentiate Examination (NLE), now approved to be amended to a National Exit Test (NEXT)
  3. It is aimed at ensuring a minimum quality standard for the MBBS (bachelor of medicine, bachelor of surgery) graduates

Basic design flaws in the process

  1. How will such an exam, currently only testing students for theory and practical (including bedside) knowledge in final year MBBS subjects, be standardized across the country remains unknown
  2. Earlier reports have suggested that the NEXT is to become another MCQ (multiple choice questions)-based test, an often used model for standardized tests across the country
  3. It would not test any higher order of learning or clinical skills and is thus unwarranted

Global models that can be used

  1. The United States Medical Licensure Examination (USMLE), which came into effect from 1992, has become more clinically applied over the years
  2. The proposed United Kingdom Medical Licensing Assessment (UKMLA) aims to ensure that the graduate “has the skills and competence to practice”, and has been structured to be implemented over many years in order to come out with a well-designed test

What should an MBBS exam do

  1. An MBBS licensing exam should not just test the medical theoretical knowledge component
  2. It has to test skills and should have both written and clinical components
  3. It should evaluate soft skills required to practice as an empathetic medical professional
  4. While an entrance test is aimed at selecting from a pool of applicants, a licentiate and exit exam serves to assess the knowledge, skill, and attitude of each qualifying MBBS doctor

Way forward

  1. With the idea of NEXT, a window of opportunity has opened to rectify ills in medical education
  2. A well-conducted NEXT would help a patient repose confidence in the competence of his/her treating doctor
  3. It should not be frittered away by reducing it to just another imperfectly designed and hurriedly implemented exam garbed in the cloak of medical education reform
Medical Education Governance in India

Cabinet nod for changes to NMC Bill


Note4students

Mains Paper 2: Governance | Issues relating to development & management of Social Sector/Services relating to Health, Education, Human Resources

From UPSC perspective, the following things are important:

Prelims level: National Medical Commission (NMC) Bill

Mains level: Issues related to medical education regulation


Amendments to the National Medical Commission (NMC) Bill

  1. The provision dealing with bridge course for AYUSH practitioners to practice modern medicine to a limited extent has been removed in the official amendments to the National Medical Commission (NMC) Bill
  2. It has now been left to the State governments to take necessary measures for addressing and promoting primary health care in rural areas
  3. There will be a final MBBS examination to be held as a common exam across the country and would serve as an exit test called the National Exit Test (NEXT)

Back2Basics

National Medical Commission (NMC) Bill

  1. The Bill seeks to repeal the Indian Medical Council Act, 1956
  2. The Bill sets up the National Medical Commission (NMC)
  3. Within three years of the passage of the Bill, state governments will establish State Medical Councils at the state level
  4. The NMC will consist of 25 members, appointed by the central government
  5. Under the Bill, the central government will constitute a Medical Advisory Council
  6. The Council will be the primary platform through which the states/union territories can put forth their views and concerns before the NMC
  7. The Bill sets up certain autonomous boards under the supervision of the NMC
  8. These boards are: (i) the Under-Graduate Medical Education Board (UGMEB) and the Post-Graduate Medical Education Board (PGMEB), (ii) the Medical Assessment and Rating Board (MARB) and (iii) the Ethics and Medical Registration Board
  9. There will be a uniform National Eligibility-cum-Entrance Test for admission to undergraduate medical education in all medical institutions regulated by the Bill
  10. There will be a National Licentiate Examination for the students graduating from medical institutions to obtain the license for practice and this exam will also serve as the basis for admission into post-graduate courses at medical institutions
Medical Education Governance in India

Cabinet clears Bill to replace Medical Council of India


Note4students

Mains Paper 2: Governance | Issues relating to development & management of Social Sector/Services relating to Health, Education, Human Resources

From UPSC perspective, the following things are important:

Prelims level: National Medical Commission Bill, Medical Council of India (MCI)

Mains level: Corruption and unethical practices in medical sector


National Medical Commission Bill now needs Parliament approval

  1. The Union Cabinet has cleared the National Medical Commission Bill, which does away with the Medical Council of India (MCI)
  2. The bill replaces MCI with a regulator that will do away with “heavy-handed regulatory control” over medical institutions
  3. It will also bring in a national licentiate examination

Key provisions of the bill

  1. Ease the processes for colleges to manage undergraduate and postgraduate courses
  2. Earlier, the MCI approval was needed for establishing, renewing, recognizing and increasing seats in a UG course
  3. Under the new proposal, permissions need only be sought for establishment and recognition
  4. The Bill proposes a government-nominated chairman and members, who will be selected by a committee under the Cabinet Secretary
  5. The 25-member NMC will have 12 ex-officio members, including four presidents of boards from leading medical institutions such as AIIMS and the ICMR; 11 part-time members and, a chairman and member-secretary

NMC to be less draconian

  1. Deterrence for non-compliance with maintenance of standards is in terms of monetary penalty
  2. The new commission will also have the power to frame guidelines for fees for up to 40% seats in private colleges and deemed universities

Why this bill?

  1. The Bill is aimed at bringing reforms in the medical education sector which has been under scrutiny for corruption and unethical practices
Medical Education Governance in India

Medical panel Bill finalised, sent to Cabinet


Note4students

Mains Paper 2: Issues relating to development and management of Social Sector/Services relating to Health.

The following things are important from UPSC perspective:

Prelims: MCI, New Medical Commission Bill.

Mains: This article talks about the New Medical Commission Bill and the need for it.

 


News

  • A Bill that will bring to an end the current system of regulation of medical education through the Medical Council of India (MCI) has been finalised and sent to the Cabinet.
  • The Bill has already been cleared by a Group of Ministers, so it is unlikely to face major problems in clearing the Cabinet.

About New Medical Commission Bill

  1. The National Medical Commission Bill envisages a four-tier structure for the regulation of medical education, with a 20-member National Medical Commission (NMC) at the top.
  2. The commission will perform overall supervision over four autonomous boards that will deal with undergraduate and post-graduate education, assessment and rating of medical institutions and registration of medical practitioners and enforcement of medical ethics.
  3. There will also be a Medical Advisory Council, constituted by the central government, like the commission and the boards.
  4. The council, which will be advisory in nature, will meet at least once a year.
  5. It will serve as the primary platform through which states will put forward their views and concerns before the NMC and help shape the overall agenda in the field of medical education and training.

Why such a bill?

  1. As a concept, the NMC has been in the making for years, given the perception of corruption in the MCI and recommendations from many committees including the Ranjit Roychowdury Committee and Parliamentary Standing Committee for Health and Family Welfare.
  2. The standing committee said that the main objective of the regulator of medical education and practice in India is to regulate quality of medical education, tailor medical education to the healthcare needs of the country, ensure adherence to quality standards by medical colleges, produce competent doctors possessing requisite skills and values as required by our health system and regulate medical practice in accordance with the professional code of ethics.
  3. However, the Medical Council of India was repeatedly found short of fulfilling its mandated responsibilities.
  4. It was the Niti Aayog that pushed for a change in the appeal structure.

The draft sent to the Cabinet incorporates two significant changes from what the Health Ministry had proposed:

  1. Only five members of the NMC will be elected while the others will be nominated by the government and the government will be the second appellate authority in case disputes arise.
  2. The first change was made after the PMO sought a reduction in the number of elected members.
  3. It would ensure that the government has more leverage and prevent the system from descending into the present state where the MCI and government are often at loggerheads on many issues.
  4. There are also ex-officio members in the commission that include nominees from the Ministry of Health, Department of Pharmaceuticals, Human Resource Development and Director General of Health Services.
  5. The real challenge for the government will be in pushing it through in Parliament, where medical education has always been a touchy subject across party lines.

 


Back2basics

About MCI

  1. The MCI was established in 1934 under the Indian Medical Council Act, 1933as an elected bodyfor maintaining the medical register and providing ethical oversight, with no specific role in medical education.
  2. The Amendment of 1956, however, mandated the MCI to maintain uniform standards of medical education, both under graduate and postgraduate; recommend for recognition/de-recognition of medical qualifications of medical institutions of India or foreign countries; accord permanent registration/provisional registration of doctors with recognised medical qualifications; and ensure reciprocity with foreign countries in the matter of mutual recognition of medical qualifications.
  3. The second amendment came in 1993,under this amendment, the role of the MCI was reduced to an advisory body with the three critical functions of sanctioning medical colleges, approving the student intake, and approving any expansion of the intake capacity requiring prior approval of the Ministry of Health and Family Welfare.
Medical Education Governance in India

[op-ed snap] Heal thyselfop-ed snap


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Note4students

Mains Paper 2: Governance | Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

From UPSC perspective, the following things are important:

Prelims level: Medical Council of India (MCI)

Mains level: MCI- problems; National Medical Commission Bill of 2016- provisions, challenges etc


News

Context

  1. Medical education scams continue unabated under the MCI’s stewardship. But merely replacing it is not the solution

  2. The regulator of medical education is itself in need of regulation

Medical Council of India (MCI)-Issues

  1. Volume of litigation that the MCI faces suggest that the regulator is neither in command nor perceived to be so
  2. It has imposed a uniform benchmark for admissions at the undergraduate and postgraduate levels
    • But different syllabi and diverse languages in different states tilt the level playing field.
  3. While the MCI is standardising entrance tests, it is failing to assure uniform, quality education for entrants who qualify.
  4. As an implication, the promise that India holds as a destination for medical tourism and education stands compromised.

National Medical Commission Bill of 2016

  • It proposes to trifurcate the functions of the MCI to reducer corruption, may prove to be superficial

Why?

  1. It would eventually leave the monopoly in accreditation intact, and opaqueness would remain a problem
  2. Intersection of private enterprise and medical education and practice is laden with incentives for corruption.
  3. Marketing of pharmaceuticals and equipment exert unhealthy influences
  4. Inspection of teaching hospitals is a scandal, with doctors and even patients being “rented” for the day.
  5. The scarcity of seats and their marked-up price tag is also a reason for corruption

Way forward

  1. Merely replacing the MCI will not suffice. Its successor must be armed with rules-based transparency to prevent rent-seeking.
  2. Examination reform could have followed

Back2basics

National Medical Commission Bill, 2016 

Salient Provisions

The bill seeks to address the following:

  1. Ensure adequate supply of high quality medical professionals at both undergraduate and postgraduate levels.
  2. Encourage medical professionals to incorporate the latest medical research in their work and to contribute to such research.
  3. Provide for objective periodic assessments of medical institutions.
  4. Facilitate the maintenance of a medical register for India and enforce high ethical standards in all aspects of medical services.
  5. Ensure that the medical institutes are flexible enough to adapt to the changing needs of a transforming nation.

Medical advisory council

The bill seeks to constitute a Medical Advisory Council which will undertake the following functions:

  1. The Council shall serve as the primary platform through which the states would put forward their views and concerns before the National Medical Commission (NMC) and shall help shape the overall agenda in the field of medical education & training.
  2. The Council shall advise the NMC on the measures to determine, maintain and coordinate the minimum standards in the discipline of medical education, training and research.
  3. The Council shall advise the NMC on measures to enhance equitable access to medical education
Medical Education Governance in India

Making medical education a public good II


  1. These factors are reportedly compelling the U.S. to revert to making higher education a public good
  2. The NITI Aayog recommendations for reforming medical education need to be viewed in this backdrop
  3. The 3-point recommendation — allowing private investors to establish medical colleges, freedom to levy fees for 60% of the students
  4. And making the exit examination the marker for quality and for crowding out substandard institutions — is expected to trigger healthy competition, reduce prices and assure quality
  5. This policy response could make the situation worse
Medical Education Governance in India

Making medical education a public good I


  1. Issue: Commercialising medical education
  2. Benefits: Incentivise investors to set up medical colleges, increase the supply of doctors, induce competition and reduce the cost of tuition fees and services
  3. Same approach in the US resulted in the entry of banks, hedge funds, private equity, venture capital, for establishing colleges
  4. This has resulted in increase in student debt, post 2002, student debt has climbed to $1.2 trillion
  5. In 2009, a review showed that in the 30 leading for-profit universities, 17% of their budget was spent on instruction
  6. But 42% on marketing, and paying out existing investors
Medical Education Governance in India

States approve proposal to replace Medical Council of India- II


  1. Representation: States have asked for more representation in the commission
  2. Consultative committee: It will be formed separately, whose function will be to advise the commission
  3. Background: In March 2016, a Parliamentary Standing Committee report had called for radical reform of the MCI
  4. It said that MCI neither represents professional excellence nor its ethos and that its composition is opaque
Medical Education Governance in India

States approve proposal to replace Medical Council of India- I


  1. Context: Question mark on ethical and professional competence of MCI
  2. Proposal: MCI to be replaced by National Medical Commission
  3. It was formulated by NITI Aayog
  4. Recommendations by states: Instead of just one chairman of the new regulatory body, there should be some members also
Medical Education Governance in India

Parliament passes bills assigning constitutional status to NEET


  1. Aim: To bring private colleges under the ambit of the Indian Medical Council (Amendment) Bill and Dentist (Amendment) Bill
  2. The bill aims to end the multiplicity of medical examinations and pave the way for fair and transparent examinations
  3. Concerns: Regional Language inclusion, disparity in fee structure and state quotas still need to be figured out
Medical Education Governance in India

Lok Sabha nods for NEET


  1. News: The Lok Sabha passed a bill awarding statutory status to the controversial National Eligibility cum Entrance Test (NEET) from the next academic session
  2. Aim: NEET aims to ensure a uniform medical and dental entrance exam
  3. The bills: The Indian Medical Council (Amendment) Bill, 2016 and The Dentists (Amendment) Bill, 2016 will amend the Indian Medical Council Act, 1956 and the Dentists Act, 1948
  4. Objectives: To end the multiplicity of examinations, have fair and transparent examinations and adopt non-exploitative process
  5. The new system will not disturb the State quotas – all India quota of 15% and State quota of 85% seats will remain
Medical Education Governance in India

British Medical Journal calls for radical revamp of MCI


  1. News: The British Medical Journal has called for a ‘radical prescription’ to reform the Medical Council of India (MCI)
  2. Background: The parliamentary panel has highlighted the MCI’s failure to oversee quality and integrity in health services in the country
  3. Purpose: To eliminate corruption and lack of ethics in healthcare
  4. Challenge: The citizens of India are strained by the dual burden of expensive and unethical healthcare

The MCI has been in the news for the wrong reasons as the Parliamentary Standing Committee on Health in its 92nd report came down heavily on various aspects of the functioning of MCI. British medical Journal also had suggested radical revamp of the MCI. This articles focuses on the medical education governance in India.

source

Let’s understand the issues under the following heads:

  • Context
  • Background
  • Weaknesses Highlighted by Parliamentary panel
  • What are the major reforms needed in MCI?
  • Measures needed to overhaul and revamp MCI
  • Mandate of Lodha committee
  • Way forward

Context:

  • MCI has been criticised for being a ‘biased’ organisation, acting ‘against larger public health goals’ and an ‘exclusive club’ of medical doctors from corporate hospitals and private practice. The British Medical Journal (BMJ) and the Parliamentary Standing Committee in their recent report have called for a ‘radical prescription’ to reform the Medical Council of India (MCI) in order to eliminate corruption and lack of ethics in healthcare.
  • SC appointed a three-member committee headed by former Chief Justice of India R M Lodha to oversee MCI.

Background

  • The MCI was established under the Indian Medical Council Act 1933 and given responsibility for maintaining standards of medical education, providing ethical oversight, maintaining the medical register, and, through amendments in 1993, sanctioning medical colleges has failed to deliver quality and integrity in the health services across India.
  • The Medical Council of India (MCI) is a statutory body entrusted with the responsibility of establishing and maintaining high standards of medical education in India.

Weaknesses Highlighted by Parliamentary panel

In its scathing report, the standing committee felt that the MCI has repeatedly failed on all its mandates over the years. The committee noted the following as some of the prominent failures of MCI.

  • Failure to create a curriculum that produces doctors suited to working in Indian context especially in the rural health services and poor urban areas. The committee felt that this has created disconnect between medical education system and health system.
  • Failure to maintain uniform standards of medical education, both at the undergraduate and post-graduate levels.
  • Devaluation of merit in admission, particularly in private medical institutions due to prevalence of capitation fees, which make medical education available only to the rich and not necessarily to the most deserving.
  • Non-involvement of the MCI in any standardized summative evaluation of the medical graduates and post-graduates.
  • Failure to put in place a robust quality assurance mechanism.
  • Very little oversight of PG medical education leading to huge variation in standards.
  • Failure to create a transparent system of medical college inspections and grant of recognition or de-recognition.
  • Failure to oversee and guide the Continuing Medical Education in the country, leaving this important task in the hands of the commercial private industry.
  • Failure to instill respect for a professional code of ethics in the medical professionals and take disciplinary action against doctors found violating the code of Ethics.

What are the major reforms needed in MCI?

  1. There is a need to restructure the MCI. It should not be an elected body dominated by vested interest but should represent all stakeholders through nomination. The MCI, as presently elected, neither represents professional excellence nor its ethos. The current composition of the Council reflects that more than half of the members are either from 21 corporate hospitals or in private practice.
  2. The MCI currently sets standards for recognition, inspects and licenses medical colleges; overseas Registration and Ethical Conduct of Doctors. It now proposes to undertake accreditation as well. Such concentration of powers creates a serious conflict of interest and provides a fertile ground for misuse of authority. So there is a need to create a transparent system of licensing of medical colleges.
  3. There should be bifurcation of the functions of MCI and recommends that different structures be created for discharging different functions.
  4. There is a need to revisit ICT tools and revisit minimum standards which are required under the act to establish medical colleges.
  5. A code of ethics which is in line with the international standards needs to be developed for the medical professionals to reduce the corrupt practices.
  6. It needs to see a balance between the number of seats available for medical courses at undergraduate and postgraduate level.

Measures needed to overhaul and revamp MCI

  1. The Parliamentary committee made a number of recommendations to overhaul the system. Some of the important recommendations of the committee are the following,
  2. Doctor – Population ratio in India is 1:1674 as against the WHO norm of 1:1000, hence the government should immediately spell out policy stance in great detail to augment the capacity of production of doctors including specialists and super-specialists at the scale and speed required to meet India’s health needs.
  3. The regulatory framework of medical education and practice should be comprised of professionals of the highest standards of repute and integrity, appointed through a rigorous and independent selection process.
  4. Urgent measures have to be taken to restructure the composition of MCI to encourage diversity so that it does not become an exclusive club of doctors.
  5. Physical infrastructure requirement should be pruned down in such a way that it should have just about 30 to 40 percent standing value in the total assessment of a medical college.
  6. Support to convert district hospitals into medical colleges. If a district hospital is converted into a medical college, it will not only be equipped with specialists of all disciplines, providing the healthcare services across the whole spectrum but will also produce some doctors in its area of operation and will thus help reduce geographical mal-distribution of doctors.
  7. The PG entrance exam should be held immediately after the final MBBS examination so that the graduate doctor could concentrate on practical skills during his internship.
  8. Ethics should be made one of the cornerstones of the syllabus of medical education.
  9. Introduction of Common Medical Entrance Test (CMET) should be done across the nation barring those States who wish to remain outside the ambit of the CMET. A common exit test should be introduced for MBBS doctors.

Mandate of the Lodha committee

  1. Lodha Committee would have complete authority to oversee all statutory functions under the MCI Act.
  2. All policy decisions of the MCI will need approvals from the Committee. It will also be free to issue remedial directions.
  3. The Committee will function for 1 year, unless a suitable mechanism is brought in earlier by it.
  4. Initially the panel will function for a year, unless suitable mechanism is brought in place earlier which will substitute the said committee.

Way forward

  • The abysmal doctor-patient ratios in India’s rural areas and poorer districts, the sanctioning of new medical colleges without ensuring trained medical faculty, the failure to produce adequate specialist doctors, and corruption in the conduct of inspections and in granting sanctions to medical colleges have wrecked the MCI’s credibility.So, there is a need to bring back the integrity which MCI has lost over the years.
  • Whether Lodha Committee manages to inculcate the changes needed in MCI or ends up being one of the numerous other attempts at cleaning up the medical education scene remains to be seen.

References:

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