Tackling public health crisis

The new year started with a lot of froth and fury from the medical community. Their anger at the proposed National Medical Commission (NMC) Bill spilled onto the streets with over two lakh doctors striking work. The Indian Medical Association called the Bill undemocratic, anti-people and anti-poor. These were strong words forcing the government to provide a platform for a greater dialogue in the Parliamentary Standing Committee.

The idea of revamping the Medical Council of India with a new architecture was first mooted in 2009. The Ministry of Health proposed establishing an overarching body called the National Commission for Human Resources for Health that would help groups of experts to set standards, norms, guidelines, accredit, license and register the doctors. The main provocation for such revamping was that the principle of elected bodies to police the medical community as embedded in the MCI posed serious conflicts of interest and did not also necessarily enable the best brains to be engaged. 

In 2013, the Standing Committee returned the National Commission for Human Resources for Health (NCHRH) bill observing that it was too centralised, provided limited participation to states and had faulty selection procedures.

Another scathing report on the functioning of the MCI of the Standing Committee got the government to come up with the NMC Bill of 2017. Reportedly, this bill was the result of several discussions with all stakeholders. Yet it got no support from any section – doctors, former policymakers or activists.

Key irritants

The NMC bill has some positive and some negative aspects. There are three positives: a) It dismantles the election process of selecting regulators providing an opportunity to enable real expertise to provide leadership to medical education and ethical practice and also enables associated disciplines to partner. After all health is far beyond just doctors to be managed by doctors alone. Management, economics and patient views are as valuable and critical; b) It seeks to standardise the ‘Indian Doctor’. The huge variance in the quality of the doctors emerging from private and public colleges, from north and south, rural and urban, required to be standardised by conducting a nationwide licentiate examination; c) It recognised the need to widen the spectrum of care providers by breaking the myth of the allopathy doctor as being the only repository of all treatment and cure. As ideas go, these were all powerful.

The bill floundered in five major ways. One, in overcentralising the process of selection and nomination into the hands of a seven-member committee; in reducing the proportion of doctors to about half, of whom again a sizeable number are from government institutions; and in minimising the participation of states. The proviso that empowers the Central government to issue orders to the NMC, state governments, and state medical councils necessarily not on policy matters alone, is too sweeping. Such powers can easily be abused in the wrong hands. Besides, the bill, in several places, provides wide discretion to the central government to overrule decisions of the NMC giving rise to potential for rent seeking.

Second, was the contentious issue of fees to be charged. The Bill provides private colleges unrestricted freedom to levy any fees for 60 per cent of the students to be admitted, dismantling the tariff committees set up by the Supreme Court to lay down reasonable ranges of fees that could be charged. This will certainly make medical education unaffordable to several meritorious students, besides compelling these students to opt for lucrative jobs than work in rural areas or public health in order to earn back the amounts spent.

The third objection was the cavalier manner in which the Commission could design bridge courses up to PG level for ayush practitioners to prescribe modern medicines.

Fourth was related to the licentiate examination. As Secretary Health, I had suggested providing an option: Those not keen to pursue higher studies or work outside the state could be registered to work in their own state after being certified by their universities, while for those wanting to study PG and go abroad or work outside the state to administer a licentiate examination to ensure uniformity in standards. In the face of such wide disparities in the quality of education, such a dual system becomes necessary, since failing the licentiate but having being found fit to practice by an accredited college through an approved system of certification but not allowed to practice can create contradictions and anomalies besides litigation. The person at a disadvantage would be those coming from the poorer background and unable to afford private tuition, studying in poorly endowed colleges in rural areas or backward states where the quality of faculty may not be so good. So, till such time the overall standards are not improved, the licentiate examination as envisaged can appear iniquitous.

Fifth, the penalties are weak. Laws and regulations are essentially for the deviants. A majority follows the law. So, penalties need to be stringent to minimize deviant behaviour. By providing only for monetary penalties to colleges that are below par – for want of faculty or infrastructure, or providing several layers of appeals to doctors found to be callous and negligent, will only ensure that none are punished. How then can quality improve? And how would the situation be any different to the current perception of an MCI, discredited only because of inaction against erring doctors and college managements?

What next?

The Standing Committee now gives an opportunity to review some of the issues mentioned above in a more comprehensive manner. Not to change is no option. Going into details of some of the bold ideas to assess their feasibility of implementation would ensure building adequate safeguards against abuse and ensure protecting patient safety and achieving good health and well-being.

The writer is former Union Secretary, Health and author of Do We Care? India’s Health System