Contentious remedies for a clear, structural malady

The primary objective of medical education should be to provide a cadre of personnel to take care of the health needs of the country. In addition, any education policy in the modern world has to take into consideration social objectives, for example equity and justice in enrolment and access. That apart, certain fundamental questions need answering too. For instance, how many years of training are required for a medical professional? What should be the purpose of a basic degree in medicine? Is specialisation required? If so, how much and how is it to be done?

The draft New Education Policy (NEP) speaks about equity, inclusiveness and sustainable development at many points, starting from the preamble. However, it is by no means clear that its recommendations will fulfil these objectives, especially in the field of medical education. For example, on page 300, it states that fees in medical colleges, both public and private, will be left to be decided by the institutions themselves. However, just a few pages later, it asserts that the cost of education should be lowered.

At another point, the policy document states that all private institutions should be not-for-profit. It appears that the committee that drafted the report hoped that this recommendation, as well as the regulatory apparatus suggested by it, by itself will take care of the problem of profiteering. However, what gives it such confidence is hard to understand given that the present policy too is to consider higher education a not-for-profit enterprise but has become a very large driver of the black economy, according to several reports. Though the document states at several points that no student should be deprived of education due to lack of finances, the solution it suggests is scholarships.

Confused thinking

The fact that on the one hand, the cost of education is sought to be lowered and on the other, fees are allowed to remain unregulated, betrays confused thinking. With the National Medical Commission Bill regulating fees only for 50% of seats in medical colleges, it looks like the commitment to equity is merely a pious homily.

At several points in the policy document, the need for a flexible education system has been stressed. One part of this flexibility is in the possibility of multiple entry and exit points. One can understand having a National Entrance Examination for admission to undergraduate courses. However, it is absolutely clear that having a National Exit Examination for MBBS as the mode of entry to postgraduate courses is neither flexible nor fair. Can a student be expected to take the exit examination multiple times if the initial score is not good enough? Are all medical colleges across the country of the same standard to ensure a level-playing field? Sealing the student’s fate once and for all through an exit examination is certainly not just.

High level of centralisation

The objectives of autonomy and adaptation to local needs are contradicted by the high level of centralisation in medical education by the National Medical Commission. The document considers separation of the functions of regulation, funding, accreditation and standard setting as absolutely necessary. However, the National Medical Commission has sought to arrogate to itself many of these functions. Further, the recommendation that diploma courses should be expanded in order to provide “intermediate specialists” lacks focus. What are these intermediate specialists supposed to do?

Multiple postgraduate courses have been started without any clear rationale. The MBBS degree has been debased to such an extent that it is considered merely a necessary requirement for postgraduation. One of the main drivers of the thirst for a postgraduate degree is the lack of adequate respectable employment opportunities for an MBBS graduate. The overwhelming privatisation of health-care delivery in India has led to the concentration of personnel in those parts where the public has the capacity to pay. Having a postgraduate degree has a multiplier effect on employability, income and respectability for the doctor. How useful it is for the society is questionable.

The policy document does not recognise that the main driver of inequity in health care is the presence of a large, poorly-regulated, for-profit sector. Private interests have ensured regulatory capture in health-care policymaking. It appears that the National Education Policy has not escaped this capture, hence the clear disconnect between the repeated exhortations to ensure equity and quality and the recommendations which will achieve neither.

Dr. George Thomas is an orthopaedic surgeon at St. Isabel’s Hospital, Chennai