The National Medical Commission Act: Travesty of reform

ON August 8, Union Minister for Health and Family Welfare Harsh Vardhan hailed the passage of the National Medical Commission (NMC) Act as historic and path-breaking and claimed that the legislation represented a visionary reform in medical education and marked an important achievement under Prime Minister Narendra Modi’s leadership. The new Act repeals and replaces the Indian Medical Council (IMC) Act of 1956, under which the Medical Council of India (MCI) was constituted. The NMC will now be the apex body governing medical education in the country, instead of the MCI, which apparently followed corrupt practices.

Yet the new Act does not even begin to address the issues that it is avowedly meant to correct. The medical community has been protesting against the legislation, which it believes will legitimise quackery: the Act provides for community health providers (CHPs) who will fill the gaps in public health care caused by the shortage of registered doctors.

The NMC Act, which has been passed by both Houses of Parliament, is aimed at providing “a medical education system that improves access to quality and affordable medical education, ensures availability of adequate and high quality medical professionals in all parts of the country, that promotes equitable and universal health care that encourages community health perspective and makes services of medical professionals accessible to all citizens, that promotes national research health goals; that encourages medical professionals to adopt latest medical research in their work and to contribute to research; that has an objective periodic and transparent assessment of medical institutions and facilitates maintenance of a medical register for India and enforces high ethical standards in all aspects of medical services; that is flexible to adapt to changing needs and has an effective grievance redressal mechanism….”

It provides for the appointment of a full-time chairperson who would be a medical professional of “outstanding ability, proven administrative capacity and integrity, possessing a post-graduate degree in any discipline of medical sciences from any university and having experience of not less than twenty years in the field of medical sciences of which ten years would be as a leader in the area of medical education”. The chairperson can be, therefore, from any university, even a private one. The NMC will have 10 ex officio members and 14 part-time members from State governments. However, the number of part-time members was increased to 22 following interventions in Parliament regarding equitable representation for States. On the same ground, Clause 4(4) b was also amended. Originally, six part-time members were to be appointed on a rotational basis from among the nominees of the States and the Union Territories to the Medical Advisory Council (MAC), an advisory body constituted by the Central government whose chairperson would be the chairperson of the NMC. This number was increased to 10.

Under the NMC Act, the MAC is the primary platform through which States and Union Territories “may set forth their views and concerns before the Commission and help in shaping the overall agenda, policy and action relating to medical education and training”. The amendments also increased the number of nominees representing State Medical Councils from States and Union Territories from five to nine.

Prelude to NMC

The prelude to the NMC effectively began five years ago with the setting up of a committee headed by Professor Ranjit Roy Choudhary to examine the ills of medical education. The committee concluded that the MCI had become a highly corrupt body incapable of regulation as it was constituted from within the medical fraternity. It recommended that independent regulators be selected through a transparent process. A Parliamentary Standing Committee that looked into the issue noted the dismal state of the health infrastructure, the exorbitant out-of-pocket expenditure of patients and the corruption in medical education, and recommended that the MCI should be wound up. It also recommended that the deficit in health care and medical education be supplemented by private players. It did not recommend a pivotal role for the government in affordable and equitable health care or medical education and, instead, emphasised that the MCI should be replaced by a new body. The government wasted no time in coming up with a Bill to effectively replace the MCI. The Bill was placed before another Parliamentary Standing Committee whose recommendations, the government claims, have been more or less accepted.

Apart from having the Bill examined by a Standing Committee, the government also received feedback on it from civil society and the medical community. Yet, while the Bill was debated in Parliament in July, doctors protested against the way the proposed legislation seemed to open the door to institutionalised quackery. There were also concerns about the provision for fee regulation in only 50 per cent of the seats in private medical colleges and deemed universities. Earlier, only 15 per cent of the seats in private medical colleges were under the management quota while the remaining 85 per cent were in the domain of the State governments. This 15 per cent was increased to 60 per cent in the first version of the Bill and then brought down to 50 per cent.

Self-defeating endeavour

A Bill avowedly designed to regulate corruption and inequities in access to health care in effect hands over medical education for profiteering. The reduction in the State government’s powers to regulate fees in private medical colleges is hard to understand. Yet the Health Minister described the regulation of fees and all other charges in 50 per cent of the seats as an “outstanding feature of the NMC Act”. The IMC Act, he said, did not have any provision for regulation of fees and States had to enter into memorandums of understanding (MoUs) with medical colleges at the time of granting Essentiality Certificates and thereby gained a handle to regulate fees of State quota seats. He said that since 50 per cent of the MBBS seats were in government colleges, the regulation of fees in 50 per cent of the seats in private medical colleges by the NMC would amount to regulating 75 per cent of the seats.

He also said: “Instead of the Centre abrogating the power to regulate fees for 100 per cent of seats available in the private sector, under this progressive Act, States have the power to take a view regarding the extent to which fee regulation needs to take place. They would now have the freedom to sign MoUs with medical colleges on the basis of mutual understanding as before. In addition, since the NMC Act has a provision for fee regulation, they will have the authority to come up with State amendments regarding regulation of fees for the remaining 50 per cent of seats.”

The State governments did not seem very impressed. Even friends and allies of the Bharatiya Janata Party such as the ruling Biju Janata Dal (BJD) of Odisha and the All India Anna Dravida Munnetra Kazhagam (AIADMK) objected to many features of the legislation, including the dilution of the States’ right to regulate fees in 85 per cent of the seats in private colleges. Among the States, especially Tamil Nadu, the introduction of the National Eligibility cum Entrance Test (NEET) has been a sore point right through.

Community health providers

The patient-doctor ratio is nowhere near the World Health Organisation (WHO) norm of one doctor for every one thousand patients, approved also by the High Level Expert Committee set up by the Planning Commission. In fact, the present ratio is one doctor to 10,000 patients. Rather than address this anomaly by setting up more quality government medical colleges that can produce quality health professionals, the NMC Act provides for the granting of a limited licence to practise medicine to a new category called mid-level health providers (MLPs), also known as CHPs. The Minister explained in a detailed press note that CHPs would be modern medicine professionals and would not deal with any alternative system of medicine. The Act describes them as being persons “connected with modern scientific medical profession”, a description that leaves a wide berth for interpretation.

The version of the NMC Bill that was introduced in December 2017 but lapsed with the dissolution of Parliament had a provision allowing AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) doctors to practise modern medicine after completing a bridge course. This was to “bridge the gap” between demand and supply. There was an uproar, and the government was forced to drop the idea. But then it came up with the idea of CHPs who will prescribe medicines independently in primary and preventive health care and in secondary and tertiary health care under the supervision of medical practitioners. “It was a pragmatic and forward-looking measure,” claimed his press note. These health professionals, whose qualifications will be decided by the NMC through regulations that will be finalised after extensive public consultation and debate, will fill the gap in rural areas where doctors are not available and are expected to counsel the population, provide early warnings, treat elementary ailments and provide early referral care to a higher facility. The Minister’s note said that doctors were a scarce resource and were indispensable in secondary and tertiary care. The CHPs will supplement medical services in preventive and primary health care. The press release also claimed that the usefulness of such MLPs had been confirmed by the WHO after their impact on health care in developed and developing countries had been studied.

In the foreword of a 2010 joint publication of the Global Health Workforce Alliance and the WHO on MLPs and their critical role in attaining the Millennium Development Goals, the executive director of the Alliance wrote that “despite their growing role, they are seldom properly integrated into the health system and are not adequately planned for nor managed”. The advantage of having MLPs, the paper noted elsewhere, was that they were much less expensive to train and employ and were less likely to migrate internally or externally.

A ‘transparent’ system

The NMC will have medical personalities selected by the government and appointed for a term of four years. The system of the medical fraternity electing people to run the apex body governing medical education has been done away with. These eminent personalities selected by the government will have to declare their assets at the time of being appointed and demitting office; declare their commercial engagement or involvement, which will be published on the NMC website (which implies they can have commercial interests and engagements); and after ceasing to hold office will for two years not accept employment in any capacity in a private medical institution that they deal with during their term as NMC members. This means that the moratorium of two years does not apply to medical institutions NMC members do not deal with.

None of the major amendments moved by MPs was accepted, barring an increase in the proportion of part-time members in the NMC and the MAC. Parliamentarians across parties, such as Sasmit Patra of the BJD, Santanu Sen of the Trinamool Congress, and K.K. Ragesh and K. Somaprasad of the Communist Party of India (Marxist), raised questions and moved amendments regarding the introduction in the NMA Bill of a final year undergraduate medical examination called the National Exit Test as a criterion for getting a licence to practise medicine. CHPs, Patra argued, should also be put through similar examinations. The Trinamool MP, who was also the president of the Indian Medical Association, described the Bill as the biggest reform in allowing “corporatisation of medical education”. He said Section 32 (allowing CHPs to practise medicine) as the “mother of quackery”.

Ragesh moved an amendment for the removal of the provision that stipulated that the National Exit Test would be the basis for admission to postgraduate speciality medical education. It was rejected, as were other amendments moved by Left Parliamentarians. Congress members did not press for any major amendment. The Dravida Munnetra Kazhagam and the AIADMK strongly protested against NEET, a position both Dravidian parties have consistently held ever since it was introduced. Students from State boards have had genuine difficulties in coping with the requirements of the centralised examination. Parliamentarians also pointed out how unscrupulous coaching centres had mushroomed in several parts of the country, luring students with the promise to help them pass NEET.

The stated objective of the NMC Act is to provide all parts of the country with high-quality medical professionals. Yet, its provisions seem designed to compromise on the quality of care accessed by the rural masses. In the name of granting more autonomy to State governments, it has attacked the federal spirit by reducing the powers of State governments to regulate fees in private medical colleges. Even its regulatory mechanism is deeply flawed.

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Author: Shirley