Remaking medical education

Remaking medical education

The Manmohan Singh-led UPA government had announced an intent to establish a National Council for Human Resources in Health (NCHRH) "as an overarching regulatory body for the health sector to reform the current regulatory framework and enhance supply of skilled personnel". This was intended to regulate competency-based medical, dental, nursing, pharmacy, public health and allied health professional education and provide a platform for promoting inter- professional education. This proposal crashed over the rocky terrain of inter- ministerial conflicts (with the HRD ministry wanting to regulate all of higher education), revision by successive health ministry committees and a critical review by the Parliamentary Standing Committee on Health. An attempt to instead enact amendments to the Medical Council of India (MCI) Act failed when forces aligned to the entrenched leadership of the MCI forced a retreat.

Caustic observations of the Supreme Court on the flaws and failings of MCI, as well as the medical profession's dismay at the Council's growing disrepute, triggered a fresh initiative by the present government to reform medical education through a bill to replace the MCI with a National Medical Commission (NMC). The bill's intent is laudable as it seeks to free medical education from regressive regulatory cobwebs and strengthen both healthcare and health research. However, protests by the Indian Medical Association (IMA) and concerns expressed by even supporters of the reform over lacunae in some provisions, have led to the bill being referred to the Parliamentary Standing Committee on Health.

The bill seeks to replace a mostly elected MCI with a largely government nominated NMC, operating through four subsidiary boards and guided by a Medical Advisory Council (MAC) which provides representation to states and union territories. It provides for a National Eligibility-cum-Entrance test (NEET) which selects entrants to undergraduate medical courses. At the end of that training, it is essential to clear a National Licentiate Examination (NLE) for permission to practice. This examination also forms the basis for selection to postgraduate medical courses. There is no clarity as to how selections for super-speciality courses will be guided by NMC. While NLE is good for standardisation at exit, the NEET at undergraduate entry faces the challenge of multiple languages and varied curricula of school education across states and may end up favouring the urban elite. Required professional competencies and curriculum requirements would be defined by Undergraduate and Postgraduate Education Boards, while other boards would look at Medical Assessment and Rating and Ethics and Medical Registration. The parallel track of postgraduate medical education, conducted by the National Board of Examinations (NBE), is protected with equivalency.

Overreach

The listed functions of NMC have an ambitious overreach. The Commission is also expected to regulate 'medical researches' and prepare the roadmap for 'healthcare infrastructure' in the country. Regulation of medical research is a function of the Department of Health Research (DHR) and the Indian Council of Medical Research (ICMR). Basic and translational medical research is also guided by the departments of Biotechnology and Science and Technology (DBT, DST), Science and Engineering Research Board (SERB), universities and the Indian Institutes of Science and Technology. It is untenable that NMC can go beyond prescribing and monitoring standards of research productivity in medical colleges. Identifying the healthcare infrastructure needs -- at all three levels of health care -- is a function of state and central health ministries and NITI Aayog. How will NMC prepare a roadmap for public and private healthcare infrastructure across the whole country?

The non-elected majority of NMC membership is a bone of contention between the IMA which wishes to protect the ideal of self-regulation by elected doctors and critics of the skewed electoral system that perpetuated the rule of a few in MCI. This failure of self-regulation, contrasted with the efficient and non- controversial boards of government-nominated experts in institutions like the All India Institute of Medical Sciences (AIIMS) and the National Board of Examinations (NBE), supports the case for the model proposed in the bill. However, the absence of public health in the areas of expertise listed for selection of NMC members is a glaring omission given the high importance accorded to that area in the National Health Policy and the NITI Aayog's Action Plan. The composition of the MAC has also been rightly criticised. Of the 67 members proposed, 25 will be NMC members with a common chairman. The prescribed quorum of 15 can create situations where 15 NMC members can meet as the MAC and advise themselves, without any state representative present. The independent advisory role of MAC is subverted by the dominant presence of those who are meant to receive the advice.

The IMA vigorously opposes the concept of a 'bridge course' to train graduates of non-allopathic systems like Ayurveda and Homeopathy for practice of allopathic medicine. While the bill rightly proposes a platform to facilitate cross-learning between these systems, IMA apprehends that the shortage of allopathic doctors in rural primary healthcare will drive the expediency of positioning these 'bridge course' trainees as allopaths, without the need to qualify in NLE. Instead, policy should provide greater support to those trained in non-allopathic healing systems in applying that knowledge and avoid undermining the value of those systems through diversion.

The IMA is also exercised about relaxation of procedures involving opening of new medical colleges, periodicity of inspections, number of seats, fee structure in private medical colleges and permission granted to foreign medical graduates. While these bear scrutiny, the bill's intent is to reduce procedural rigidity so as to rapidly scale up the production of medical graduates and specialists. Even as the Standing Committee reviews the NMC bill, it should challenge the health ministry to present a plan for matching health professional education -- across all categories -- to national health system needs in terms of numbers, competencies, distribution, cadres and team structures. This function cannot be outsourced to NMC.

(The writer is president, Public Health Foundation of India, New Delhi).