Over the past few days, there have been expressions of concern in various fora over a few clauses of the National Medical Commission (NMC) Bill, now enacted. Even medical professionals have protested. According to media reports, there are five primary concerns. These pertain to the National Eligibility-cum-Entrance Test (NEET)/National Exit Test, empowering of community health providers for limited practice, regulating fees for only 50% seats in private colleges, reducing the number of elected representatives in the Commission, and the overriding powers of the Centre.
First, a focus on the examinations. For the past few years, a separate NEET is being conducted for undergraduate and postgraduate courses. In addition there are different examinations for institutes such as the All India Institute of Medical Sciences and the Jawaharlal Institute of Postgraduate Medical Education and Research. This Act consolidates multiple exams at the undergraduate level with a single NEET and in turn avoids multiple counselling processes. NEXT will act as the final year MBBS examination across India, an entrance test to the postgraduate level, and as a licentiate exam before doctors can practise. It aims to reduce disparities in the skill sets of doctors graduating from different institutions. It would also be a single licentiate exam for graduates across the world. Thus, the government has in effect implemented a ‘One-Nation-One-Exam’ in medical education.
Second, concerns have been expressed over the limited licence to practise for community health providers. We have to appreciate that even with about 70% of India’s population residing in the rural areas, the present ratio of doctors in urban and rural areas is 3.8:1; 27,000 doctors serve about 650,000 villages of the country. A recent study by the World Health Organisation shows that nearly 80% of allopathic doctors in the rural areas are without a medical qualification. The NMC Act attempts to address this gap by effectively utilising modern medicine professionals, other than doctors in enabling primary and preventive health care. Evidence from China, Thailand and the United Kingdom shows such integration results in better health outcomes. Chhattisgarh and Assam have also experimented with community health workers. Further, the Act requires them to “…qualify such criteria as may be specified....” thereby ensuring quality.
The next issue relates to the capping of fees. It is an open secret today that private medical colleges are capitation fee-driven, resort to a discretionary management quota and often have charges of corruption levelled against them. The Indian Medical Council Act, 1956 has no provision for fee regulation. Until now, ‘not-for-profit’ organisations were permitted to set up medical colleges, a process involving enormous investments and a negotiation of cumbersome procedures. The NMC Act removes the discretionary quota by using a transparent fee structure. It empowers the NMC to frame guidelines for determination of not only fees but all other charges in 50% of seats in private colleges to support poor and meritorious students.
It would be simplistic to assume that a rise in unethical practices in this profession is solely the result of private medical education. While a cap on fees is necessary, there is also a need for incentives to attract private investors. In any case, the transparency that NEXT provides would lead to fee regulation through market forces. The Act also provides for rating of colleges. Thus, reducing entry barriers for setting up medical colleges, along with their rating, is expected to benefit students. They would be able to make an informed decision before seeking admission.
The next issue is of representation in the NMC. A report of the then vice-chancellor, NITI Aayog, on reforms in medical education says: “The current electoral process of appointing regulators is inherently saddled with compromises and attracts professionals who may not be best suited for the task at hand. Indeed, there is ample evidence that the process has failed to bring the best in the field in regulatory roles. The process is based on what is now widely regarded as a flawed principle whereby the regulated elect the regulators.” The Act, therefore, provides for a transparent search and selection process with an eclectic mix of elected and nominated representatives, both in the search committee and the commission itself. The government has further addressed the concern of preponderance of selected members in the commission by adding members from State medical councils and universities.
Finally, we need to view the issue of overriding powers of the Centre in the context that the Medical Council of India, even if directed by the government on critical matters, may not always pay heed. In public emergencies, citizens expect the government to address issues. In the current set-up, it may not be possible all the time. Also, the government should be able to give directions so that NMC regulations align with its policy. Hence, these powers. The use of such authority would follow the principle of natural justice: the NMC’s opinion would be sought before giving directions.
In a nutshell
While some sections of people have sought to create a negative perception about select clauses of the Act, they have not highlighted other features. The Act establishes the Diplomate of National Board’s equivalence to NMC-recognised degrees — a long-pending demand. It also promotes medical pluralism. Then, there is a paradigm shift in the regulatory philosophy from an input-based, entry barrier for education providers without corresponding benefits, to its becoming outcome-focused. Both the number of doctors and their skill sets are expected to improve. Autonomy to boards and segregation of their functions will avoid a conflict of interest and reduce rent-seeking opportunities. And ‘quacks’ are liable to face imprisonment or be fined or both. The Act ends inspector raj.
The efforts of successive governments have now culminated with the NMC Act replacing the IMC Act. There is no denying that medical education needs continuous reforms in order to usher in improvements in health care. There cannot be just one solution. The NMC Act is a serious attempt to meet the primary need of more medical professionals in the country; it is a beginning.
Sumant Narain is a civil servant and ex-director, NITI. The views expressed are personal