Seeking sweeping reforms to medical education, largely opposed by the medical fraternity, the bill attempts to set up a regulatory body called the National Medical Commission in place of the tainted Medical Council of India (MCI). As quoted by the Health Ministry, almost 75% of total medical seats in the country would be available at reasonable fees once the new National Medical Commission (NMC) Bill is assented into law
By: Neelam Jhangiani
Medical education system in India is set to witness significant changes as the National Medical Commission Bill, 2019 heads for implementation. The Rajya Sabha recently passed the bill with two amendments and referred it to the Lok Sabha, which too passed the amendments. President Ram Nath Kovind gave assent to a key legislation aimed at ushering in mega reforms in the medical education sector and replacing the nearly 63-year-old Indian Medical Council Act. The National Medical Commission (NMC) Bill, passed by both houses of Parliament will soon be notified in the gazette.
Seeking sweeping reforms to medical education, largely opposed by the medical fraternity, the bill attempts to set up a regulatory body called the National Medical Commission in place of the tainted Medical Council of India (MCI). As quoted by the Health Ministry, almost 75% of total medical seats in the country would be available at reasonable fees once the new National Medical Commission (NMC) Bill is assented into law.
Checking out the details
Fifty percent of the total MBBS seats in the country are in government colleges, which have nominal fees and of the remaining seats, 50% would be regulated by the NMC that will replace the corruption-plagued Medical Council of India (MCI). A country with a population of 1 billion has only 76,000 MBBS seats of which 40,000 are in government colleges and 36,000 in private sector. According to the bill, state governments would still have the liberty to decide fees for remaining seats in private medical colleges on the basis of individual MOUs signed with colleges on the basis of mutual agreement.
Scholarships provided by the states based on merit would continue in order to make medical education affordable to all students. NMC 2019 will allow management of 50% of seats at the highest rates and even for the rest of the 50%, NMC will only provide guidelines and not regulate. Some 279 out of 506 medical colleges in the country are in private sector and 52% of 68,000 medical seats are private. The government has invested more than Rs. 10,000 crore in creating government seats in the past five years and are also setting up 21 new AIIMS to boost the medical education sector and this trend of creating government seats will continue in future.
Keeping interests in mind
With the Indian Medical Council Act 1956 having no provision for regulation of fees, currently, some states regulate the fees of some seats in private colleges through MoUs signed with college managements. The Bill seeks to repeal the Act and committees chaired by retired High Court Judges have been set up to fix fees in private colleges as an interim measure.
Deemed to be Universities claim that they are not covered by these committees. The interests of poor meritorious students as well as promoters of private medical colleges need to be balanced in order to expand the number of seats on offer. The transparency provided by NEXT results would lead to regulation of fees through market forces. As per the statement, colleges would have to provide quality of education commensurate to the fees charged by them, otherwise there would be no takers for their management quota seats. According to the ministry, rating would be provided by Medical Assessment and Rating Board or MARB for medical institutions based on the standard of education and training. This will serve to regulate fee through market forces.
Somehow, the medical fraternity does not see any constructive changes with the Bill, the main unacceptable provisions pointed out by Dr. Uttam Thakur, President, Resident Doctors Association ARD-PGIMER are: it will increase corruption and decrease autonomy in the profession, Central Government will have power to override the decisions/recommendations of National Medical Commission and Autonomous Boards constituted there-under [Sec 45(1& 2)], undue favour to the private medical colleges and Deemed Universities will be given by decreasing the percentage of seats under controlled fees structure from 85% to 50% [Section 10( 1)(i)], and lastly, there will be decreasing representation of Elected Members from 75% (as was in MCI) to 20% in NMC [Section 4 (4)].
There are further rueful opinions. “Mixing various systems of medicine at the curriculum level will effectively produce a hybrid doctor and will be the best way to destroy the identity of modern medicine,” says Dr. R.V. Asokan, Honorary Secretary General, Indian Medical Association. “So, in a decade all the doctors in the country will be a product of corruption of all systems of medicine.”
The failure & the birth
The Statement of Object and Reasons of the Bill says the IMC had failed to keep pace with time and various bottlenecks had crept into the system with serious detrimental effects on medical education, ultimately affecting delivery of quality health services.
Parliamentary panel working on the matter recommended restructuring and revamping of the regulatory system of medical education and practices. “However, the healthcare industry is divided over why MCI needs restructuring when it consists elected members from the medical fraternity,” says Dr. Girdhar Gyani, Director General at Association of Healthcare Providers-AHPI (India).
It was also argued by some sections of industry that elections were not held in a democratic manner. Additionally, there had been umpteen number of corruption allegations on MCI. There were instances where MCI and MOHFW were at loggerheads. Although MCI was an autonomous regulator but in practical terms it was argued that it should take into consideration what MOHFW was contemplating and not blatantly oppose.
Comparing with global education standards
India’s medical fraternity has a shortage of specialists compared to foreign nations. Most specialists in hospitals are stretched between patient care and administrative duties and are unable/unwilling to commit time to train the next generation of doctors. The policy needs to address the skill and availability gap in medical faculty first before looking at the expansion of the student base.
“The government will need to structure incentives (grants, tax rebates, and subsidies) to attract the best minds in India and globally to get engaged in teaching,” says Gerald Jaideep, CEO, Medvarsity Online Ltd.
With the inclusion of Skill Lab in the new syllabus, lot of improvement is evidently mentioned. Though high-fidelity medical simulation considered equivalent to aviation simulation in developed countries is still to receive its due recognition in our country. The real question is that in this era when technology is available to practice in a real time environment, why not to use it before practicing on the patients. Just like a pilot is supposed to have XYZ number of simulation flying hours before he/she even applies for a license, why can’t our medical education be developed on a similar platform?
Although, we do have colleges like DY Patil University, who have been training their students for the past six years using a High-Fidelity Simulation. They have developed protocols and process by which all UG & PG students undergo various simulation-based courses prior to clinical postings. This not only makes them a better clinician, but also improves their learning curve drastically.
The success mantra in high-fidelity medical simulation is not just the technology of the mannequin but it’s the administrative & academic interface. “Till date, our country has not set standards in both these areas. To address this issue of “Who should be a Simulation Faculty /Instructor?” We tied up with Mayo Clinic USA and executed India’s first Mayo Clinic Simulator Instructor Program in our campus. We possess 14 Mayo Clinic trained simulation instructors,” says Dr. Nitin Sippy, Administrative Head – Medical Simulation Laboratory, DY Patil University.
The university has executed more than 2000 workshops and trained 40,000 + healthcare professionals on high-fidelity medical simulation.
Amendments to the Bill
The National Medical Commission (NMC) Bill, which was in the eye of a controversy underwent three amendments and backchannel talks with parties to see the light of the day.
The number of members in the NMC increased from 14 to 22, giving more representation to the states in the body. If the number of members to be nominated by the states is increased, the states get a better representation in two years rather than four years agreed the health minister. Three amendments were introduced — two in Section 4 of the Bill. Now, Section 4 (4) (b) says, “The following persons shall be appointed as part-time members of the Commission, namely… (b) 10 members to be appointed on rotational basis from amongst the nominees of the states and union territories, under clauses (c) and (d) of sub-section (2) of Section 11, in the Medical Advisory Council for a term of 2 years in such manner as may be prescribed”. Section 4 (4) (c) reads, “9 members to be appointed from amongst the nominees of the states and union territories, under clause (e) of sub-section (2) of Section 11, in the Medical Advisory Council for a term of 2 years in such manner as may be prescribed.”
Healthcare services have been in focus more so in the recent past. Bringing in of new health policy and implementing of Ayushman Bharat have been landmark decisions by the NDA government. These initiatives can only be effective if we fulfil 4-A’s of universal health coverage i.e. making healthcare Available, Accessible, Affordable and Acceptable.
The major limitation in terms of availability of specialist doctors was found to be the tumbling block. The fact that 80% of specialist’s positions were found to be vacant in 5500 community health centres, prompted the government to hasten up reforms in medical education and as one of the main objectives of NMC. Terming the NMC Act, a ‘progressive’ legislation, government says the Bill will ensure probity, quality education and bring down costs of medical education. It is hoped that new NMC will prove to be vigilant, vibrant, transparent and credible and will usher reforms in medical education and which in turn will facilitate reforms in the Indian healthcare systems.
National Exit Test: Pros & Cons
The current policy only allows medical specialists to attend to the critical care treatments or procedures that they have specialised in. The new NEXT (National Exit Test) policy allows MBBS graduates entry by training them with necessary surgical skills. It, therefore, will equip them in assisting the senior doctors in more critical positions and over a period of time, fill the gap of needed specialists. This examination also would serve as one providing license to practice.
The same examination will be the basis for selection to post graduation. The entire student community is agitated over how can a low-profile licentiate exam identify the talent for post graduate education. However, as stated by the government, this provision will eliminate the need for students to approach multiple colleges and take part in multiple counselling processes for admission. This will save students and their families’ unnecessary physical and financial trauma.
Section 15(1): A common final year undergraduate medical examination, to be known as the NEXT shall be held for granting licence to practice medicine as medical practitioner and for enrolment in the State Register or the National Register, as the case may be. The examinee who fails to clear the National test in spite of having passed the MBBS examination and required internship would not be able to practice till he clears the said NEXT.
This thereby defeats the very objective of the government to provide greater number of trained health manpower to the extent that in the name of clearing the Exit Test as a pre-condition, those not clearing would be of no utility or use for rendering the healthcare services. Likewise, a medical graduate who otherwise by virtue of acquiring the said qualification was entitled to practice and earn his livelihood would be barred of the same till he clears the NEXT. The NEXT also facilitates inclusion of the foreign medical graduates as registered medical practitioners on limited testing. This again, is a bone of contention among the industry.