Anaemic Bill

The Bill to regulate medical education and govern human resource in health is a highly diluted version of the original draft.

Distortions in the area of Human Resource for Health (HRH) are the root cause of many of the ills facing the health sector in India. Among them is the shortage of qualified medical professionals. The estimated density of 19 health workers (qualified and unqualified) per 10,000 population is nearly 25 per cent less than the World Health Organisation (WHO) norm of 25 (doctors, nurses and midwives). The doctor density is only six. Further, there are large variations across States and the distribution is highly skewed in favour of urban areas. This disparity is particularly significant from the perspective of achieving universal health coverage (UHC) at least in the medium term for a couple of decades.

Of more serious concern is the higher density of health workers in the private sector. Today, nearly 70 per cent of health care in the country is provided by the private sector. The consequence is higher per capita cost of health care and a large number of unfilled posts in the public sector. Medical education is in a mess, with private medical colleges and deemed universities, many of them dubious, mushrooming all over the country. Their opaque entrance examination systems and capitation fee-based admission procedures have placed a huge financial burden on students and denied a large number of them access to medical education.

Medical education in the country is regulated by the Medical Council of India (MCI), a statutory body set up under the Indian Medical Council (IMC) Act of 1956. Similarly, nursing, pharmacy and dental education are governed by the Indian Nursing Council (INC), the Pharmacy Council of India (PCI) and the Dental Council of India (DCI). Their primary role is to maintain the standards of professional education and to register and license health professionals and provide guidance on ethics.

In 1993, the IMC Act was amended to include Section 10 A, which allows medical/dental colleges to be set up only with the approval of the respective councils and the government. Corruption in medical education, it can be said, started with this amendment, which concentrated all power at the Centre and left State governments with no control over granting permission to start medical/dental colleges. This also centralised corruption, with virtually one individual, Ketan Desai, Chairman of the MCI for many years, manipulating all the deals. Following media reports and sting operations, demonstrations by activists, and later support from the Prime Ministers Office, Desai was arrested and the MCI suspended in May 2010. Currently, an ad hoc Board of Governors (BOG) manages the affairs and responsibilities of the MCI. It is widely known that in Desais racket, the Ministry of Health and Family Welfare (MoH&FW) was an active collaborator; under the IMC Act, the Ministry has a role in framing rules and regulations and it is the ultimate authority to grant approval and recognition to new colleges/institutions.

In 2009, the Yash Pal Committee, set up by the Ministry of Human Resource Development (MHRD) to recommend reforms in higher education, recommended the setting up of an overarching statutory body called the National Commission for Higher Education and Research (NCHER) and doing away with the multiplicity of regulators such as the University Grants Commission (UGC), the All India Council for Technical Education (AICTE), the MCI, and so on. The Knowledge Commission, too, had made observations on the deficiencies in the current system and recommended a similar body.

The Bill to create the NCHER is pending in Parliament. It has sections dealing with health education too. But for reasons that are not clear, a separate statutory body, the National Commission/Council for Human Resource in Health (NCHRH), has been mooted to oversee medical education and govern HRH. This was first announced by President Pratibha Patil in Parliament on June 4, 2009. On June 26 that year, the government constituted a task force for the purpose under the chairmanship of Naresh Dayal, the then Health Secretary. It had 11 other members. The task force had to deliberate upon the structure and function of the proposed HRH commission and prepare a draft Bill.

The first draft of the Bill was ready in 2009 itself. It went through several revisions before the final draft was introduced in the Rajya Sabha on December 22, 2011, and was referred to the Parliamentary Standing Committee on Health and Family Welfare. The committee was expected to submit its report in three months but is yet to do so. Similarly, the NCHER Bill, which has some overlapping elements with the NCHRH Bill, was introduced in the Rajya Sabha about a week later. It was referred to the departmental standing committee, which was expected to submit its report by February 15, 2012, but is yet to do so.

Some of the essential provisions of the NCHRH Bill are as follows:

According to the statement of objectives and reasons, The Bill seeks to consolidate the law in certain disciplines of the health sector and promote human resources in the health sector and provide for a mechanism for the determination, maintenance, coordination and regulation of standards of health education throughout the country to ensure adequate availability of human resources in all States. Towards that it seeks to establish the NCHRH to regulate professional councils in the health sector. Since the Bill seeks to establish an all-inclusive mechanism to determine and regulate the standard of health education in the country, the different statutory regulatory councils shall stand repealed on such date as will be decided by the Central government.

Besides the NCHRH, the Bill also seeks to establish a National Board for Health Education (NBHE) and a National Evaluation and Assessment Committee (NEAC) with distinct responsibilities for regulating and enforcing educational standards, assuring quality and governing medical practice along ethical norms. In particular, the NBHE will replace the National Board of Examinations (NBE) to take, as the statement of objectives says, measures to facilitate and promote academic studies and research in emerging areas of health education with focus on professional health education and to ensure uniform augmentation of trained specialists and super specialists. The NEAC will take measures to develop and regulate the process of evaluation and assessment of institutions imparting health education and programmes conducted therein, and monitor the functioning of agencies recommended by the commission.

The NCHRHs permission will be required to establish an educational institution. A scheme for setting up an institution has to be submitted to the NCHRH, which will, in turn, refer it to the NEAC, whose recommendations will be the basis for the grant of permission by the commission. In case the person making the proposal is not informed of a decision within a year of the submission of the scheme, it shall be deemed to have been approved. The NCHRH will determine and maintain the minimum standard of human resource in health education by conducting studies to assess the needs of States. It will conduct elections in the new national councils and provide grants to the NBHE, the NEAC and the councils, and regulate the entry of foreign institutions in consultation with NBHE under any law that may come into force.

New National councils

New national councils to be known as the Medical Council of India, the Dental Council of India, the Nursing Council of India (NCI) and the Pharmacy Council of India (PhCI) will replace the existing councils and a Paramedical Council of India (PCI) will be established for the discipline of paramedics. Also, State governments will be conferred powers to constitute the respective councils in the States.

Unlike the existing councils, the new bodies will have restricted functions and powers, which will basically include maintenance of national registries of professionals in their disciplines. Every person who desires to practise medicine, sign a medical certificate or give evidence in a court as an expert has to be enrolled in the national or State registers. The Bill also seeks to establish an NCHRH Fund to meet the expenses of the various bodies.

The Bill also lists penalties for various offences, such as operating an institution without permission, practising without being enrolled, and enrolling without a screening test. Also, if a person is aggrieved by the professional services rendered by a medical practitioner enrolled in the register, a complaint may be filed with the State council within 60 days. The council shall decide on the complaint within 120 days of receiving the complaint. The national and State councils will also have the power to inquire into any complaint of professional misconduct against anyone enrolled in the register. If the person is found guilty, the council can impose certain penalties, including removal from the register. However, there is a provision for appeal to the ethics committee of the NCHRH against any decision of the national council.

The Bill has seen many revisions in the past three years. Its final form is a highly diluted version of the draft of July 2010, which is perhaps the most comprehensive of all the drafts. Its final form as tabled in Parliament does have some serious problems. One of its main flaws is the concentration of power in the hands of a few persons and authorities appointed by the MoH&FW, which can result in a high degree of commercialisation.

Effectively, what the Bill has achieved is a mere transfer of power concentrated in the erstwhile MCI to a new body that will be largely controlled by the Ministry. Its undue involvement with medical and other aspects of professional health education has been the bane of the Ministry all along and the reason for its neglect of other fundamental health care issues. Thus the NCHRH in its present form is likely to be beset with the same ills as the present framework for HRH.

All appointments members of the commission, the NEAC and so on will be made by the Central government, which means the MoH&FW. Since many of these positions are for five-year terms, with extension being a possibility, the appointees will be accountable only to the Health Ministry and not to the public or other stakeholders. The accountability of many of the governing members and officers is not laid out and this can lead to a situation similar to what existed with the erstwhile MCI, noted a former member of the task force. While the Indian Medical Association (IMA) is on very weak ground in its opposition to the short-duration rural health worker course, the Bachelors degree in Rural Health Care (BRHC), its protest against the NCHRH on the grounds of over-centralisation of powers in regulating medical education and the profession seems valid.

The commission will have 13 members. The original draft envisaged a very small commission with four or five members. Now, besides the Chairman, the commission will have four whole-time members from the disciplines of medicine, dentistry, nursing, pharmacy and paramedics and eight part-time members representing medicine, dentistry, nursing, pharmacy, paramedics, management, science and technology, and law. All of them are to be appointed by the government. The constitution of the commission should be more broad-based. In fact, the persons chosen should have a holistic view of the medical profession rather than a discipline-centric one that sees the health care system only from the medical professions point of view and ignores the social and other determinants of health care. The commission does not have any provision to include all the stakeholders, such as State governments, universities, national associations of health professionals and civil society members.

Board for all reasons

The National Board for Health Education, which will replace the current National Board of Examinations as proposed in the Bill, is supposed to deal with all health-related professional education medical, dental, nursing, pharmaceutical and paramedical. The Board must, therefore, have a wider representation and a larger administrative structure specific to each discipline. The relationship of the Board with the NEAC is also not clear. The Board is the most important entity in the Bill. It is supposed to deal with all academic matters, such as curriculum, new courses, standards, examinations and screening tests (for being included in the registers). However, the Bill falls short of detailing fully the functions of the two entities.

The national and State councils proposed in the Bill are mainly responsible for registrations and ethical conduct. But the States and universities do not have any role in the commission and the Board. Thus the councils will have a large membership just to maintain medical registries and professional ethics. Health being a State subject, this might lead to problems in the future, especially for backward States, point out experts. Also, for this very reason, they opine, primary registration should be with the State councils and the Indian Medical Register (IMR) should be maintained by the national council.

The National Conference of State Medical Councils held in February unanimously resolved thus: The National Commission for Human Resources for Health Bill, 2011, being proposed by the Ministry of Health... is unanimously opposed in its present format (sic), as the council members felt that the present MCI and State Medical Councils needs (sic) to be strengthened and implemented effectively with democratic norms instead of taking their autonomy.

Some experts have, in fact, argued for having a general council to oversee and protect the NCHRH from overcentralisation. The NCHER Bill, for instance, envisages a comprehensive General Council. For the NCHER, too, the general council can be on the same lines, they point out.

In one of its earlier versions, the Bill had a provision for a National General Assembly for Health, the highest level of governance for the NCHRH, to be constituted by the government. This was a good concept because all functionaries under the commission were appointees of the government. Basically, the assemblys decisions would have formed the basis for decision-making by the commission and other bodies envisaged in the Bill. However, this was dropped in the later version.

Similar is the omission of AYUSH professionals in the final draft, which was there in the July 2010 version of the Bill. AYUSH medical professionals form a substantial fraction of health care providers. With their exclusion, another Bill to regulate their activities is needed. The Bill also ignores the mid-level health care providers and traditional health practitioners, who do not strictly come under AYUSH.

In conclusion, what began as a determined exercise to bring about reforms in the health education sector and improve the quality and availability of HRH in the country has ended up in a final draft that is a highly watered down version of the original draft.