Medical Education Governance in India

Medical Education Governance in India

Standards must not be lowered to certify Ayurveda postgraduates surgeons

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Sushrut Samhita

Mains level : Debate over mixopathy

This conundrum of different standards for surgical training must be solved because patient safety is far more important than the career progression of Ayurvedic postgraduates.

Practice Question: There is a need to rethink on the recent notification of AYUSH Ministry allowing Ayurveda postgraduates to conduct surgeries keeping the safety of the patient at the centre. Discuss.

The current clash

  • The clash between the allopathic and AYUSH fraternities is about the AYUSH practitioners’ “right” to conduct surgeries.
  • The Ayurvedic fraternity maintains postgraduates in Shalya and Shalakya (two surgical streams among 14 post-graduate courses) are taught procedures listed in the curriculum.
  • The oldest-known surgical specialist was, in fact, an Ayurvedic surgeon/sage Sushrut (600 BC) who wrote the Sushrut Samhita — a profound exposition on conducting human surgery which continues to receive worldwide acclaim.
  • Surgery was practised by Ayurvedic surgeons long before the advent of western medicine.
  • Allopaths question the logic of Sushrut’s millennia-old pre-eminence bestowing the right to practise modern surgery. Ayurvedic surgeons may not know the hidden risks of every surgical procedure and how to surmount sudden mishaps.
  • The Ministry of AYUSH justifies its notification on the ground that not all vaidyas but only postgraduates qualifying from two surgical streams have been authorized to perform selected surgeries.

The contentious issue

  • The moot point is about who decides whether Ayurvedic surgeons possess sufficient proficiency to conduct these surgeries safely and by what standard their skills are judged.
  • Surgical proficiency cannot be judged by different standards in one country — particularly when less-educated patients would rather save money than question a surgeon’s qualifications.
  • The statutory regulatory body for AYUSH education is the Central Council of Indian Medicine (CCIM). CCIM has only promoted what private college managements demand, propelled, in turn, by students’ need to earn a stable income as medical professionals.
  • In this misplaced zeal to give better earnings to the Ayurvedic vaidyas, CCIM has sidelined many skills that Ayurveda could have included, which are relevant even today.
  • This has subjugated the curriculum to nurture more and more replicas of doctors of modern medicine.
  • This has killed the knowledge, purity and goodness of classical Ayurveda, which ironically is the Ayurveda in high demand in Europe, Russia and America.

Nothing can replace practise and training to perform surgery

  • When it comes to surgery, it is not knowledge but rigorous training and continuous practice which makes for perfection. Both require clinical material and most Ayurvedic hospitals do not have a fraction of the surgical patients found in allopathic general hospitals.
  • Allopathic students of surgery learn first by watching and then performing scores of surgeries under supervision.
  • Surgical skills are by no means impossible to learn but they become difficult to master without continuous training and supervision.
  • Due to the paucity of patients, limited scope for training and access to gaining hands-on practice, it is hazardous to allow all Shalya and Shalakya postgraduates to undertake surgical procedures.
  • In the last three decades, specialization has excluded general surgeons from performing what was once considered routine. For example, only an ENT surgeon can perform a tonsillectomy.
  • Therefore, to notify that Ayurvedic postgraduates in surgery can perform omnibus operations runs counter to the norm in India and in other countries.

Way forward

  • In performing surgery, the only benchmark should be the duration of hands-on training received — counted by surgeries under supervision, and being judged through external evaluation.
  • Every surgeon’s skills and competence must be tested by applying exactly the same standards before she/he can operate.
  • This conundrum of different standards for surgical training must be solved because patient safety is far more important than the career progression of Ayurvedic postgraduates.

Medical Education Governance in India

Issues related to Nursing Sector in India

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Not Much

Mains level : Nursing education in India

The year 2020 has been designated as “International Year of the Nurse and the Midwife”.

But the nursing education in India displays a grim situation. It suffers poor quality of training, inequitable distribution, and non-standardized practices.

Nursing sector in India

  • Nurses and midwives will be central to achieving universal health coverage in India.
  • India’s nursing workforce is about two-thirds of its health workforce. Its ratio of 7 nurses per 1,000 population is 43% less than the World Health Organization norm; it needs 2.4 million nurses to meet the norm.
  • The sector is dogged by structural challenges that lead to poor quality of training, inequitable distribution, and non-standardized practices.

Uneven regulation

Nursing education in India has a wide array of certificate, diploma, and degree programmes for clinical and non-clinical nursing roles.

  • The Indian Nursing Council regulates nursing education through prescription, inspection, examination, and certification. 91% of the nursing education institutions are private and weakly regulated. The quality of training of nurses is diminished by the uneven and weak regulation.
  • The current nursing education is outdated and fails to cater to the practice needs. The education, including re-training, is not linked to the roles and their career progression in the nursing practice.
  • There are insufficient postgraduate courses to develop skills in specialities and address critical faculty shortages both in terms of quality and quantity.
  • These factors have led to gaps in skills and competencies, with no clear career trajectory for nurses.
  • Multiple entries point to the nursing courses and lack of integration of the diploma and degree courses diminish the quality of training.
  • A common entrance exam, a national licence exit exam for entry into practice, and periodic renewal of licence linked with continuing nursing education would significantly streamline and strengthen nursing education.
  • Transparent accreditation, benchmarking, and ranking of nursing institutions too would improve the quality.
  • The number of nursing education institutions has been increasing steadily but there are vast inequities in their distribution. Around 62% of them are situated in southern India.
  • There is little demand for postgraduate courses. Recognizing the need for speciality courses in clinical nursing 12 PG diploma courses were rolled out but the higher education qualification is not recognized by the recruiters.
  • The faculty positions vacant in nursing college and schools are around 86% and 80%, respectively.

Gaps in education, services

  • There is a lack of job differentiation between diploma, graduate, and postgraduate nurses regarding their pay, parity, and promotion.
  • The higher qualifications are underutilized, leading to low demand for postgraduate courses.
  • Those with advanced degrees seek employment in educational institutions or migrate abroad which has led to an acute dearth of qualified nurses in the country.
  • Small private institutions with less than 50 beds recruit candidates without formal nursing education. They are offered courses of three to six months for non-clinical ancillary nursing roles and are paid very little.
  • The Indian Nursing Act primarily revolves around nursing education and does not provide any policy guidance about the roles and responsibilities of nurses in various cadres.
  • Nurses in India have no guidelines on the scope of their practice and have no prescribed standards of care and is a major reason for the low legitimacy of the nursing practice and the profession. This may endanger patient safety.
  • The Consumer Protection Act holds only the doctor and the hospital liable for medico-legal issues; nurses are out of the purview of the Act. This is contrary to the practices in developed countries where nurses are legally liable for errors in their work.

Institutional reforms required

  1. The governance of nursing education and practice must be clarified and made current.
  2. The Indian Nursing Council Act of 1947must be amended to explicitly state clear norms for service and patient care, fix the nurse to patient ratio, staffing norms and salaries.
  3. The jurisdictions of the Indian Nursing Council and the State nursing councils must be explained and coordinated so that they are synergistic.
  4. Incentives to pursue advanced degrees to match their qualification, clear career paths, the opportunity for leadership roles, and improvements in the status of nursing as a profession should be done.
  5. A live registry of nurses, positions, and opportunities should be a top priority to tackle the demand-supply gap in this sector.
  6. The public-private partnership between private nursing schools/colleges and public health facilities is another strategy to enhance nursing education. NITI Aayog has recently formulated a framework to develop a model agreement for nursing education.
  7. The Government has also announced supporting such projects through a Viability Gap Funding.

Practice Question:

Q. Discuss the various issues related to nursing sector in India and measures to be taken to address them.

A Bill that could spell hope

  • The disabling environment prevalent in the system has led to the low status of nurses in the hierarchy of health-care professionals. In fact, nursing has lost the appeal as a career option.
  • The National Nursing and Midwifery Commission Bill currently under consideration should hopefully address some of the issues highlighted.
  • These disruptions are more relevant than ever in the face of the COVID-19 pandemic.

Medical Education Governance in India

Surgery as part of Ayurveda

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Sushrut Samhita

Mains level : Read the attached story

Last month, a government notification listed out specific surgical procedures that a postgraduate medical student of Ayurveda must be “practically trained to acquaint with, as well as to independently perform”.

Q.Allowing modern surgeries to Ayurveda professionals is a mixopathy and an encroachment into the jurisdiction and competencies of modern medicine. Critically analyse.

What is the notification?

  • The notification mentions 58 surgical procedures that postgraduate students must train themselves in and acquires skills to perform independently.
  • These include procedures in general surgery, urology, surgical gastroenterology, and ophthalmology.

The issue

  • The notification has invited sharp criticism from the Indian Medical Association, which questioned the competence of Ayurveda practitioners to carry out these procedures.
  • They have called the notification as an attempt at “mixopathy”.
  • The IMA has planned nationwide protests against this notification and has threatened to withdraw all non-essential and non-Covid services.

Surgery as a part of Ayurveda

  • It is not that Ayurveda practitioners are not trained in surgeries, or do not perform them.
  • In fact, they take pride in the fact that their methods and practices trace their origins to Sushruta, an ancient Indian sage and physician.
  • The comprehensive medical treatise Sushruta Samhita has, apart from descriptions of illnesses and cures, detailed accounts of surgical procedures and instruments.
  • There are two branches of surgery in Ayurveda — Shalya Tantra, which refers to general surgery, and Shalakya Tantra which pertains to surgeries related to the eyes, ears, nose, throat and teeth.
  • All postgraduate students of Ayurveda have to study these courses, and some go on to specialize in these and become Ayurveda surgeons.

Distinctions in surgical procedures

  • For several surgeries Ayurvedic procedures almost exactly match those of modern medicine about how or where to make a cut or incision, and how to perform the operation.
  • There are significant divergences in post-operative care, however.
  • The only thing that Ayurveda does not do is super-speciality surgeries, like neurosurgery or open-heart surgeries.
  • For most other needs, there are surgical procedures in Ayurveda. It is not very different from allopathic medicine.

Ayurvedic surgeries before the notification

  • PG education in Ayurveda is guided by the Indian Medical Central Council (Post Graduate Education) Regulations framed from time to time.
  • Currently, the regulations formulated in 2016 are in force. The latest notification of last month is an amendment to the 2016 regulations.
  • The 2016 regulations allow postgraduate students to specialise in Shalya Tantra, Shalakya Tantra, and Prasuti evam Stree Roga (Obstetrics and Gynecology), the three disciplines involving major surgical interventions.
  • Students of these three disciplines are granted MS (Master in Surgery in Ayurveda) degrees.

Arguments in favour

  • Ayurveda practitioners point out that students enrolling in Ayurveda courses have to pass the same NEET (National Eligibility-cum-Entrance Test).
  • Ayurveda institutions prescribe textbooks from modern medicine, or that they carry out surgeries with the help of practitioners of modern medicine.
  • Their course, internship and practice also run parallel to the MBBS courses.
  • Postgraduate courses require another three years of study. They also have to undergo clinical postings in the outpatient and In-patient departments at hospitals apart from getting hands-on training.
  • Medico-legal issues, surgical ethics and informed consent is also part of the course apart from teaching Sushruta’s surgical principles and practices.

So, what is new?

  • Ayurveda practitioners say the latest notification just brings clarity to the skills that an Ayurveda practitioner possesses.
  • The surgeries that have been mentioned in the notification are all that are already part of the Ayurveda course. But there is little awareness about these.
  • A patient is usually not clear whether an Ayurvedic practitioner has the necessary skill to perform one of these operations.
  • Now, they know exactly what an Ayurveda doctor is capable of. The skill sets have been defined. This will remove question marks on the ability of an Ayurveda practitioner.

What are the IMA’s objections?

  • IMA doctors insist that they are not opposed to the practitioners of the ancient system of medicine.
  • But they say the new notification somehow gives the impression that the skills or training of the Ayurveda doctor in performing modern surgeries are the same as those practising modern medicine.
  • This, they say, is misleading, and an “encroachment into the jurisdiction and competencies of modern medicine”.
  • The IMA has condemned the move calling it predatory poaching on modern medicine and its surgical disciplines.
  • The IMA has demanded that the notification, as well as the NITI Aayog, move towards ‘One Nation One System’ (of AYUSH) be withdrawn.

Medical Education Governance in India

Dealing with the problems of medical education

Note4Students

From UPSC perspective, the following things are important :

Prelims level : Not much

Mains level : Paper 2- Issues with medical education in India

The article discusses the issues with medical education in India and how it affects the principle of equality.

Role of private entities

  • Due to demand for high-quality medical care on the one hand and constraints on public resources on the other, private entities have been permitted to establish medical educational institutions to supplement government efforts.
  • In the field of health care, there is a continuing shortage of health-care personnel.
  • The infrastructure required for high-quality modern medical education is expensive.
  • The three stated objectives of medical education has been — providing health-care personnel in all parts of the country, ensuring quality and improving equity.
  • None of the three stated objectives of medical education has been achieved by the private sector.
  • Though they are supposed to be not-for-profit, taking advantage of the poor regulatory apparatus and the ability to both tweak and create rules, these private entities, with very few exceptions, completely commercialised education.

Demand for regulation and equity

  • There have been attempts to regulate fees, sometimes by governments and sometimes by courts.
  •  These efforts have not been fruitful.
  • The executive, primarily the Medical Council of India, has proven unequal to the task of ensuring that private institutions comply with regulations.
  •  When the courts are approached, which issues are seen as important depends on the Bench.
  • It was in this situation that led to the introduction of the National Eligibility-cum-Entrance Test (Undergraduate), or NEET-UG, as a single all-India gateway for admission to medical colleges.
  •  Challenged in courts, after an initial setback, the NEET scheme has been upheld.

How NEET affected equity

  • NEET may have improved the quality of candidates admitted to private institutions to some extent, but it seems to have further worsened equity.
  • Under any scheme of admission, the number of students from government schools who are able to get admission to a medical college is very low.
  • With NEET, the number has become lower.
  • The high fees of private medical colleges have always been an impossible hurdle for students from government schools, whatever the method used for admission.

Way forward

  • The basic cause of inequity in admission to higher educational institutions is the absence of a high quality school system accessible to all.
  • Allowing government medical colleges to admit students based on marks in Standard XII and using NEET scores for admission to private colleges will be more equitable right now.

Conclusion

Only a resolute government, determined to ensure that economic policy facilitates quality and equity in education, can do it.

Medical Education Governance in India

National Medical Commission

Note4Students

From UPSC perspective, the following things are important :

Prelims level : National Medical Commission

Mains level : Not Much

The National Medical Commission (NMC) has replaced the Medical Council of India (BoG-MCI), as per information released by the Health Ministry.

National Medical Commission

  • National Medical Commission (NMC) is an Indian regulatory body of 33 members which regulates medical education and medical professionals.
  • It replaced the Medical Council of India (MCI) on 25 September 2020.
  • The Commission grants recognition of medical qualifications, gives accreditation to medical schools, grants registration to medical practitioners, and monitors medical practice and assess the medical infrastructure in India.
  • The NMC will have four separate autonomous boards: under-graduate medical education, post-graduate medical education, medical assessment and rating and ethics and medical registration.

It’s legal backing

  • The NITI Aayog had recommended the replacement of MCI with NMC.
  • The decision was approved by most states and after its approval by the Prime Minister and NMC bill was passed by parliament and approved by President on 8 August 2019.
  • National Medical Commission ordinance was brought in to replace Medical Council of India in early 2019 through an ordinance issued in January 2019 by the President of India.
  • The Supreme Court had allowed the Central Government to replace the medical council and with the help of five specialized doctors monitor the medical education system in India, from July 2017.
  • The government dissolved the MCI in 2018 and Indian Medical Council Act, 1956 (102 of 1956) stands repealed.

Medical Education Governance in India

[op-ed snap] Back to the blackboard

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 drugs

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 health

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 accreditation

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 remain

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?

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?

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.

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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