Medical Education

A cure worse than the disease

Print edition : November 11, 2016

Students of a medical college in Karnataka on graduation day. The 92nd Parliamentary Standing Committee’s report came down heavily on the MCI, which has the task of establishing and maintaining standards in medical education.

The NITI Aayog’s draft Bill that proposes the setting up of a National Medical Commission dispenses with regulation of infrastructure and fees and gives a free hand to private players.

IN March this year, the 92nd Parliamentary Standing Committee report of the Ministry of Health and Family Welfare on the abysmal state of medical education was released with fanfare. The report focussed on and had a critique of the Medical Council of India (MCI), which has the task of establishing and maintaining high standards in medical education. The MCI also has the responsibility to regulate the quality of medical services in the country.

The parliamentary committee report also looked at the state of health care in the country, the quality and quantity of health care services and access to such services. The report dwelled at length on the constitution of the MCI, which, it said, was responsible for the rot that had set in in medical education, from the process of granting accreditation to medical colleges to the mushrooming of medical colleges in the private sector and the exorbitant amounts charged under the name of capitation fees.

On March 28, even as the report was being discussed and written about in various fora, the government constituted a three-member committee under the NITI Aayog to examine aspects of the Indian Medical Council Act, 1956, and to suggest reforms in medical education. The committee acknowledged that its efforts were hugely facilitated by the parliamentary standing committee’s report. By August 7, the committee was ready with its recommendations, including proposing a new Bill that would repeal the IMC Act and pave the way for the constitution of a National Medical Commission (NMC). In the name of regulating medical education, the committee’s document is a blueprint for the further privatisation of medical education. The committee placed the document and the draft Bill for public consultation. Among the thousands of representations it has already received, some are in favour of dismantling the MCI and others have suggested reforming it. The MCI itself has expressed serious reservations about the draft Bill and the proposed NMC. But, the people who lauded the 92nd Standing Committee report have reason to be worried about the draft Bill and the architecture of the NMC. Some of them have expressed their reservations on what they see as the NITI Aayog committee’s flawed understanding of medical education and health care.

“Medical education is at the core of access to quality health care in any country,” says the very first line in the background note to the NITI Aayog committee’s report. The cat is out of the bag in the second line itself as the note says: “Accordingly, a flexible and well functioning framework underlying medical education is essential for the well being of the nation.” The IMC Act, it says, was passed with this in mind but it has not kept “pace with time”. Various flaws, the report says, had crept into the system, thereby affecting medical education and quality of medical services.

The NITI Aayog committee’s observations draw on the recommendations in the 92nd Parliamentary Standing Committee report and in the report of the Ranjit Roy Chaudhary Expert Committee which was constituted in July 2015. It suggested the creation of a regulatory structure and the NMC through a new Act. Interestingly, much of the justification for the arguments given by the NITI Aayog committee came from the report of the Parliamentary Standing Committee, which was “convinced that the much-needed reforms will have to be led by the Central government. The MCI can no longer be entrusted with the responsibility in view of its massive failures. The people of India will not be well served by letting the modus operandi of the MCI continue unaltered to the detriment of medical education and decay of the health system. The government must therefore fulfil its commitment to preserve, protect and promote the health of all Indians by leading the way for a radical reform which cleanses the present ills and elevates medical education to contemporary global pedagogy and practices while retaining focus on national relevance.”

The NITI Aayog committee, too, assigns a larger role to the Central government in the constitution of the NMC. The committee also refers to a Supreme Court order of May 2016 ( Modern Dental College and Research Centre vs State of M.P. and others) that directed the Central government to act on the recommendations of the Ranjit Roy Chaudhary committee. The Supreme Court also set up an oversight committee under former Chief Justice of India, Justice (retd) R.M. Lodha to oversee the functioning of the MCI and address other issues that were considered by the Standing Committee, pending a final decision at the executive or legislative levels. This meant that once the NMC was set up, the oversight committee would cease to exist. Interestingly, the MCI in its submission to the NITI Aayog committee pointed out that allegations of corruption against it were baseless and that none of them had been proven in any court of law. It further opined that there was nothing wrong with the system of partly electing and partly nominating members to the MCI and that the MCI’s structure need not be tampered with. It pointed out that the parliamentary committee did not give the MCI a hearing before finalising its report.

Panel recommendations

The proposed structure by the NITI Aayog paves the way for the proliferation of private medical colleges and, by extension, private health care. It also dilutes the few regulations that existed in the MCI. For instance, while it points to a conflict of interest in the present electoral system in the MCI of “regulators appointing regulators”, the solution it offers is a broad-based search committee-cum-selection committee that would, though the report does not say so, be formed by the government.

It suggests the creation of a medical advisory council representing the States and the Union territories to “articulate the national agenda for medical education”. It gives more powers to the Central government since the NMC is to be the policy making body and the members, including the chairperson, are to be appointed by the Central government. It also provides for the constitution of four autonomous boards for the regulation of undergraduate medical education, postgraduate medical education, accreditation and assessment of institutions, and the practice of the profession itself.

On the face of it, the NITI Aayog committee seems to have covered everything. But its real intent is exposed in the regulatory philosophy that it espouses and outlines. It says: “It is strongly felt that the input based regulatory philosophy underlying the current MCI has turned out to be a high entry barrier facing education providers without corresponding benefit in terms of quality medical education. Hence, the NMC regulation will be overwhelmingly based on outcomes rather than inputs. The input based regulation is largely based on an inspection regime verifying an institution’s compliance to a pre-specified standard and focusses more on infrastructural issues rather than teaching quality and learning outcomes.” It is baffling that the committee does not feel the need for pre-specified standards and fails to see the connection between infrastructure for medical education on the one hand and the quality of medical education and the subsequent outcome on the other.

More bafflingly, it says: “However, the deviation from standards need not result in the de-recognition/stoppage of admission since this gives the regulator a disproportionate and asymmetric power over the regulated institutions and creates opportunities for rent seeking. While penalties should not be ruled out, the deviations should be corrected principally through periodic publication of ratings of medical institutions. Deviations would be handled through a grievance redressal mechanism rather than inspections. Only when an institution, undeterred by fines multiple times, remains non-compliant with NMC directives, should the de-recognition option be exercised. The institutions should be given due opportunity to present their case before the NMC resorts to the nuclear option.”

Regulatory philosophy

The recommendations of the committee are in consonance with the overall regulatory philosophy of the Bharatiya Janata Party (BJP)-led National Democratic Alliance (NDA) government at the Centre. This is the same philosophy of less regulation that is being pushed in the area of labour laws in the name of reform. That laws are cumbersome is a sentiment that has been articulated by every quarter of the government. The self-certification by industries regarding their compliance with laws is somewhat similar to the proposal of periodic publication of ratings of medical institutions.

The philosophy of deregulation extends to the realm of fees as well. It uses the logic that stringent laws and regulation stymie growth and would encourage a parallel underground system. The report suggests the further liberalisation of the regulatory regime. The Parliamentary Standing Committee had raised the issue of capitation fees, saying it was disproportionately high in many cases, a sentiment that has been around for nearly two and a half decades, ever since medical education became a business. Rather than address this, the NITI Aayog committee says that the NMC “should not engage in fee regulation of private colleges”. The reasons it gives are baffling, but not surprising: one, micro-management could potentially encourage rent-seeking behaviour in the NMC; two, a fee cap would discourage the entry of private colleges, thereby undermining the objective of rapid expansion of medical education; and three, enforceability of such a regulation is doubtful and is bound to encourage the continuation of the underground economy consisting of capitation fees and payments demanded under various pretexts throughout the duration of education.

The report argues that a stop-gap arrangement of the Supreme Court for the fixation of fees by private colleges did not take off. Yet, lest it appear that it was in favour of an unregulated fee system, the report says that the NMC can be empowered to fix norms for regulating fees for a proportion of seats (not exceeding 40 per cent of the total number of seats) in private medical colleges. For the rest, 60 per cent, the institutions may be given “full freedom to charge the fees they deem appropriate”. This, it hopes, will provide for cross subsidisation from the rich to the more meritorious but poor students and students from disadvantaged groups.

The report actually discusses whether the established principle of allowing only not-for-profit organisations to set up medical colleges should be revisited. The committee wonders whether the government should include a proviso to permit “for profit” organisations to invest in medical colleges, the logic being that there is a shortage of providers. Using the same logic that regulation has not worked, it says that the current ban on for-profit institutions has not prevented private institutions from extracting profits through non-transparent and possibly illegal means. Therefore, it says that any restriction on the class of education providers will be counterproductive. It recommends “de-linking the condition for affiliation/recognition from the nature of the promoter of the medical college (viz, Trust, not for profit company)”.

A national network of doctors and public health activists called the Alliance of Doctors for Ethical Healthcare has strongly criticised the proposals of the committee and the draft Bill. It said that the “overall direction of the treatment being suggested by the NITI Aayog may be even worse than the disease it is supposed to remedy”. And that instead of checking the commercialisation of medical education and advocating more public regulation, the NITI Aayog report was championing more commercialisation and privatisation of medical education. The alliance has objected to the following aspects: the suggestion to allow private players to use district hospitals to run medical colleges; the absence of a provision to set up a board of medical ethics in the draft Bill, a feature that was recommended by the Parliamentary Standing Committee; the absence of a proviso to regulate the activities of medical associations that indulged in unethical practices; and the complete elimination of elected representatives in the NMC, which, the alliance noted, was not the way forward. The alliance also felt that the NITI Aayog’s report was hardly consultative, as claimed. It said that it had given a detailed submission to the NITI Aayog and that it was not even acknowledged.

The NITI Aayog’s antidote to the ills of medical education may only widen the gap in terms of access to medical education and access to health care itself, and, more importantly, it will have a negative impact on the quality of health care.

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