<div>The first of the modern professions, namely medicine, law, teaching (university) and divinity, gave its practitioners social recognition, responsibility, autonomy and power. <br /><br />Altruism and service orientation embedded in the term profess brought responsibility to live up to the expectations. In lieu of altruistic commitment, the professions received autonomy to self-regulate. The provision of monopoly over their occupation made them very powerful–socially, economically and politically.<br /><br />The medical profession has enjoyed such privileges unchallenged, but not any longer. The most important message coming out of the 92th Parliamentary Standing Committee (PSC) report is that society no longer trusts its most revered professionals, the doctors.<br /><br />But what makes the report a compelling reading is that it is logical and is based on evidence. The report does not talk about plastic surgery in ancient India but chronicles the failures of the present healthcare system and the self-regulation of medical profession in the form of the Medical Council of India (MCI).<br /><br />In the past, the MCI made headlines due to allegations of massive corruption, particularly in recognising and regulating private medical colleges. The arrest of its president, Dr Ketan Desai, by the CBI on corruption charges in 2010, followed by the dissolution of the MCI– only to restore it in 2013–the court cases and re-entry of Dr Desai and his supporters into the MCI has given rise to cynicism and disillusionment among the people. <br />In public perception, gradually the MCI became synonymous with corruption. So much so that the president of the MCI, while testifying before the PSC, admitted without any embarrassment that some corruption was normal during the process of recognition of and increasing number of students in private medical colleges.<br /><br />In January 2014, the then health secretary Keshav Desiraju held a meeting with five people for consultation on the MCI issue. Interestingly, every issue covered by the PSC and the recommendations, including replacing and/or bifurcating functions of the MCI, were put on the table for discussion by him. <br /><br />Desiraju also told us that he was under tremendous pressure to sign papers allowing backdoor entry to Dr Desai into the MCI and was worried about such arrogant power. Of course, Desiraju was shunted out the next month, but the issues flagged by him remained and has found a voice in the PSC report.<br /><br />Fixing the system<br /><br />If corruption existed in social vacuum, it would have been easy to pick and throw it out like a bad apple. Mere talk of corruption or moral degradation of few men or women without any reference or links to the determinants of such corruption would serve no purpose. In case, after a scandal or two, the situation returns to normal and old business resumes.<br /><br />The PSC report does not disappoint us on that count as it goes into the issues of what caused the failure of the eight-decade old MCI, and the roots of corruption in it. Such issues could be categorised into three major determinants: Healthcare system, medical education and conflict of interest.<br /><br />Healthcare system: The MCI is a part of the larger healthcare system and hence, the two cannot be artificially separated. That also means that problems found in the MCI as a regulator of medical education and profession cannot be fixed without fixing some corresponding source of problems in the system.<br /><br />The PSC report correctly identifies the unbridled expansion of private sector and non-regulated private market as the major problems of healthcare system. The links between poverty, ill-health, and the out-of-pocket healthcare expenditure resulting in 63 million people being rendered poor every year are graphically portrayed in the report. There is no doubt that corruption in the MCI is only an expression of the corruption in the healthcare system at the ground level – be it “cut practice” where private providers charge commission for each other at the expense of the patients, the arbitrariness in charging for services, unnecessary investigations and surgeries etc. Though it does lament on the decreasing government expenditure in establishing new public services in the under-served areas, it falls short of critiquing it comprehensively.<br /><br />Medical education: For the first time a government report asserts unambiguously that privatisation of medical education has resulted in reservation of medical seats to those who can afford tens of millions of rupees as capitation fee (which is otherwise illegal), while the meritorious students from the under-privileged classes are kept out. <br /><br />It also points out the concentration of medical education institutions in south and western regions of the country. The underlying factor of course is the market–services and education would get located in areas where there is money and not in the under-served poor localities. The recommendation to establish medical colleges in every district is indeed welcome, so is the recommendation for a national entrance test as it would go a long way in creating a level-playing field.<br /><br />Conflict of interest: The failure of the disciplinary or ethics regulation is due to the unhealthy solidarity among doctors. The report convincingly argues for more non-doctors in the regulatory set up. <br /><br />Such orientation expresses the society’s vote of no-confidence in self-regulation of medical profession. One only hopes that these recommendations will be implemented and the profession, education and the system would be made accountable to the people.<br /><div><br />(The writer is editor, Indian Journal of Medical Ethics, Mumbai.)</div></div>
<div>The first of the modern professions, namely medicine, law, teaching (university) and divinity, gave its practitioners social recognition, responsibility, autonomy and power. <br /><br />Altruism and service orientation embedded in the term profess brought responsibility to live up to the expectations. In lieu of altruistic commitment, the professions received autonomy to self-regulate. The provision of monopoly over their occupation made them very powerful–socially, economically and politically.<br /><br />The medical profession has enjoyed such privileges unchallenged, but not any longer. The most important message coming out of the 92th Parliamentary Standing Committee (PSC) report is that society no longer trusts its most revered professionals, the doctors.<br /><br />But what makes the report a compelling reading is that it is logical and is based on evidence. The report does not talk about plastic surgery in ancient India but chronicles the failures of the present healthcare system and the self-regulation of medical profession in the form of the Medical Council of India (MCI).<br /><br />In the past, the MCI made headlines due to allegations of massive corruption, particularly in recognising and regulating private medical colleges. The arrest of its president, Dr Ketan Desai, by the CBI on corruption charges in 2010, followed by the dissolution of the MCI– only to restore it in 2013–the court cases and re-entry of Dr Desai and his supporters into the MCI has given rise to cynicism and disillusionment among the people. <br />In public perception, gradually the MCI became synonymous with corruption. So much so that the president of the MCI, while testifying before the PSC, admitted without any embarrassment that some corruption was normal during the process of recognition of and increasing number of students in private medical colleges.<br /><br />In January 2014, the then health secretary Keshav Desiraju held a meeting with five people for consultation on the MCI issue. Interestingly, every issue covered by the PSC and the recommendations, including replacing and/or bifurcating functions of the MCI, were put on the table for discussion by him. <br /><br />Desiraju also told us that he was under tremendous pressure to sign papers allowing backdoor entry to Dr Desai into the MCI and was worried about such arrogant power. Of course, Desiraju was shunted out the next month, but the issues flagged by him remained and has found a voice in the PSC report.<br /><br />Fixing the system<br /><br />If corruption existed in social vacuum, it would have been easy to pick and throw it out like a bad apple. Mere talk of corruption or moral degradation of few men or women without any reference or links to the determinants of such corruption would serve no purpose. In case, after a scandal or two, the situation returns to normal and old business resumes.<br /><br />The PSC report does not disappoint us on that count as it goes into the issues of what caused the failure of the eight-decade old MCI, and the roots of corruption in it. Such issues could be categorised into three major determinants: Healthcare system, medical education and conflict of interest.<br /><br />Healthcare system: The MCI is a part of the larger healthcare system and hence, the two cannot be artificially separated. That also means that problems found in the MCI as a regulator of medical education and profession cannot be fixed without fixing some corresponding source of problems in the system.<br /><br />The PSC report correctly identifies the unbridled expansion of private sector and non-regulated private market as the major problems of healthcare system. The links between poverty, ill-health, and the out-of-pocket healthcare expenditure resulting in 63 million people being rendered poor every year are graphically portrayed in the report. There is no doubt that corruption in the MCI is only an expression of the corruption in the healthcare system at the ground level – be it “cut practice” where private providers charge commission for each other at the expense of the patients, the arbitrariness in charging for services, unnecessary investigations and surgeries etc. Though it does lament on the decreasing government expenditure in establishing new public services in the under-served areas, it falls short of critiquing it comprehensively.<br /><br />Medical education: For the first time a government report asserts unambiguously that privatisation of medical education has resulted in reservation of medical seats to those who can afford tens of millions of rupees as capitation fee (which is otherwise illegal), while the meritorious students from the under-privileged classes are kept out. <br /><br />It also points out the concentration of medical education institutions in south and western regions of the country. The underlying factor of course is the market–services and education would get located in areas where there is money and not in the under-served poor localities. The recommendation to establish medical colleges in every district is indeed welcome, so is the recommendation for a national entrance test as it would go a long way in creating a level-playing field.<br /><br />Conflict of interest: The failure of the disciplinary or ethics regulation is due to the unhealthy solidarity among doctors. The report convincingly argues for more non-doctors in the regulatory set up. <br /><br />Such orientation expresses the society’s vote of no-confidence in self-regulation of medical profession. One only hopes that these recommendations will be implemented and the profession, education and the system would be made accountable to the people.<br /><div><br />(The writer is editor, Indian Journal of Medical Ethics, Mumbai.)</div></div>
