The National Medical Commission Bill has sent ripples across the medical fraternity with strikes and protests — with the aim to refresh medical practice in India, this Bill requires severe scrutiny before final implementation to ensure ethical healthcare, explores Yogesh Kant.
Since 2009, when the idea of revamping the Medical Council of India was first mooted and was replaced by way of an Ordinance in 2010, several discussions ensued on this topic. Yet, when the National Medical Commission (NMC) Bill was placed on the table of the Lok Sabha, it was greeted with anger and a day-long strike by private doctors across the country. In the face of stiff opposition cutting across party lines, the Bill has been referred to the Parliamentary Standing Committee.
The article seeks to explain four major irritants: the architecture of the proposed Commission; licensing of doctors; cross practice and permitting practice without prior screening; and fees. These aspects need a careful review in view of the long-term implications for the nature of doctors we produce and operate in our country.
The Bill seeks to replace a 106-member elected body with a 65-member Medical Advisory Council (that includes 25 members of the NMC); a 25-member NMC with four verticals consisting of all 12 members that deal with setting the curriculum, regulating standards and maintaining registration. An expert believes that if the advisory council meets once a year, the NMC is expected to meet quarterly and the verticals monthly. The secretary of the Commission is expected to run the day-to-day matters, coordinating different bodies and the various expert committees that each may constitute. For discharging such important duties, his stature, experience or medical knowledge are yet not specified, other than a postgraduate degree.
The government reserves the power to issue directives that the NMC, states and elected state medical councils have to comply with. Besides, the government is also empowered to dilute the norms and criteria laid down for sanctioning colleges, approving degrees, courses and granting permissions to anyone to practice medicine. The Centre can even overturn punishment meted out to a doctor found guilty of negligence or malpractice by the state Medical Council, the Ethics and Medical Registration Board and the NMC. Such centralisation and bureaucratisation of the regulator are unprecedented, more so because the NMC already consists of all the technical advisors of the Ministry: DGHS, DG ICMR, heads of its premier institutions like AIIMS, PGI Chandigarh etc.
If NEET was considered necessary for ensuring a minimum standard of knowledge to be possessed by students to deal with the tough medical syllabus, this Bill provides for an exit examination. The provocation is that there are various standards across the country that influence the quality of doctors being produced. Therefore, a licentiate examination would help standardise the "Indian doctor". The exam is for being eligible to get a licence to practice and also qualify to pursue postgraduation.
The problem circumscribes the fate of students who undergo a rigorous five-year study in an accredited medical college, pass an approved examination process consisting of viva and practicals and are declared fit to practice. But then, they fail to qualify an MCQ paper conducted by the NMC. Their options are either to spend huge amounts in private coaching centres or practice clandestinely. The students most likely to be affected will be those from backward provinces and poorer families. This provision thus needs further deliberation.
The third issue is a joint sitting of the Commission and the heads of the AYUSH Councils to design bridge courses for undergraduate and postgraduate courses under which AYUSH practitioners would be eligible to prescribe allopathic medicines. Such AYUSH doctors do not have to undergo any licentiate examination or screening and yet are registered by the NMC, providing dual registration.
The Indian Medical Association (IMA) called for a 12-hour shutdown to protest, what it describes as the "anti-people and anti-patient" National Medical Commission (NMC) Bill, 2017, that seeks to replace the Medical Council of India (MCI). Because of this, many doctors across the country have gone on a protest. The IMA, which has 2.77 lakh members, has termed the Bill as anti-poor and anti-people and said it makes the system prone to corruption. It has demanded amendments in the Bill which was tabled in the Lok Sabha. The Bill that is purported to eradicate corruption, the IMA alleges, is "designed to open the floodgates of corruption."
The fraternity of doctors alleges that the NMC is an anti-poor bill with a pro-private management clause, it claimed and added, "The bill allows ayurvedic as well as homoeopathic doctors to practice allopathy after a six-month bridge course."
The IMA demands that one elected representative in the NMC is from the Registered Medical Graduates of every state and there is no separate registration for AYUSH. It demands that the minimum qualification to practice modern medicine shall remain MBBS and there should not be the provision for any bridge courses.
"It took more than seven years to move in that direction. The Union Cabinet finally cleared the long-pending National Medical Commission (NMC) bill on 15 December, 2017. The bill is likely to be tabled in Parliament in this winter session and if passed will replace the Indian Medical Council Act, 1956," said a doctor. Ideally, the reform should have come from within the medical profession. But since that did not happen, it is now being imposed from outside. This, incidentally, looks like the first in many medical reforms that are likely to be enacted in the near future.
"Unfortunately, due to continuous doctor-bashing from all sides, the medical profession has developed a sense of despondency. It has become so paranoid in its outlook that every action, every course-correction that comes from the outside is looked upon with suspicion. The knee-jerk reaction, therefore, is to reject such reforms. But an honest cursory look at the proposed NMC bill tells another story – it comes across as a well-intentioned move, barring, of course, a few deficiencies that can still be rectified," said a professor at a medical college.
"The proposed bill opens by stating: "It aims to create a world-class medical education system." It then goes on to introduce the National Eligibility cum Entrance Test (NEET) to ensure uniformity in admission to undergraduate studies in medical schools. This pan-India entrance test has the potential to purge the medical admission process. It is aimed to ensure that only merit is counted in medical education. It is pertinent to note that even admission to private medical colleges will be based on NEET, which will abrogate the corrupt and unscrupulous practices that existed all along," said a medical activist.
He further added that it is most heartening to read the bill's commitment to, "equitable access to medical education". It is very unfortunate that we lag far behind in quality medical research when compared to the western world. This has created a distinct disadvantage for India in regard to advances in the health delivery system. The proposed NMC bill seeks to reverse this drawback. "To facilitate it's functioning, the bill constitutes four independent working boards: One for undergraduate medical education, one for postgraduate medical education, one for medical assessment and rating and the last one for maintaining the national medical register and regulating medical conduct.
"With a phenomenal increase in the number of medical institutions, courses they offer at the undergraduate and postgraduate levels, examinations they conduct at various levels and the number of students who pass out and join the medical practice; it is well in order that such a structured organisation is created to oversee and regulate the profession," the bill reads.
"On the flip side, the most serious flaw the bill has is to completely do away with the elected representatives of the medical profession. With all its members coming as government's nominees or by virtue of ex-officio government positions they hold, the National Medical Commission would look like just an extension of the health ministry. The fine balance that existed till now between the elected members and the nominated ones ensured a fair degree of autonomy for the regulatory body. It made sure that the policy decisions taken by the health ministry were checked and balanced by the council. That democratic tradition now seems to be coming to an end," highlighted the RDA AIIMS.
"The medical profession has been demanding absolute autonomy for its regulatory bodies. But if the government takes complete and unfettered charge of the council, it is goodbye to autonomy forever. Additionally, all the grants and funds to run the regulatory body will come from the central government, making it completely dependent and helpless," said Dr Vijay Gurjjar, Former RDA president, AIIMS.
"Clause 35 of the proposed bill raises a serious doubt – under the heading "Recognition of Other Medical Qualifications", it states that the "central government may by notification recognise qualifications granted by any other body in India". Does this mean other lateral streams of medicine (such as Homoeopathy, Ayurveda, Unani etc) are going to be accommodated under NMC and allowed to practice modern medicine? This ambiguity needs to be removed from the bill," Dr Harjeet Bhatti said.
The bill is slated to be tabled in the Parliament during this session. There is hope that these anomalies are corrected before the bill is finally validated. "There are certain issues that the regulatory body will have to urgently take note of. For one, the issue of standardisation of medical education is not yet sufficiently addressed. There are medical institutes that impart excellent education and train their students very well for independent practice. Then there are institutes that have very poor infrastructure and insufficient faculty; thus, they are unable to train their students for challenges of independent practice," said a professor, UCMC.
"All these students get their degrees and there is no way to tell one from another. If the sick are to reap the full benefit of the health delivery system, standardised education and training will have to be given to every doctor coming out of the medical college," he added.
"The physician licensed to practice in one state has to register anew in another state if he wishes to practice there. It's time the concept of reciprocity is introduced here; a common national register is maintained and the physician is allowed to practice anywhere in India." Dr Harjeet further added.
Lastly, it's time to introduce medical or clinical audit in our health delivery system. If we want quality improvements in patient care and ensure favourable outcomes, a review system will have to be put in place that would ensure that activities are conducted toeing the correct line.
In conclusion, laws are only as good or as bad as the way they are implemented. Repealing an act and replacing it with another is not necessarily the best way to usher in reform. It all depends upon the kind of people we appoint to implement the law; and how honestly, sincerely and competently they choose to implement it.