ON April 27, when a three-judge Supreme Court bench led by Justice A.R. Dave, hearing a public interest litigation petition filed by the non-governmental organisation Sankalp Charitable Trust, ruled that all medical admissions would be held through the National Eligibility cum Entrance Test (NEET), it only sought to uphold the Constitution Bench’s April 11 ruling recalling a July 2013 order. It also perhaps echoed the prevailing sentiment for reforms in medical education and the health system as a whole. The order upheld the validity of a centralised NEET for admission to medical colleges, and it was expected that the Central government would implement the same. After all, the government’s counsel had argued for that. But it was not to be.
The judgment held that “all associated with the conduct of the exam, including Central government, State government, institutions, police, etc., will extend all necessary support” to the Central Board of Secondary Education (CBSE) and permit the use of security measures, such as electronic and communication devices and jammers “for timely and fair conduct of the NEET”.
The judges held that “in view of the submissions made on behalf of the respondents, we record that NEET shall be held as stated by the respondents. We further clarify that notwithstanding any order passed by any court earlier with regard to not holding NEET, this order shall operate. Therefore, no further order is required to be passed at this stage.”
While there is no dispute over the need for a system like the NEET, the apprehension that students from State boards and rural areas may not be able to compete and qualify in the examination set as per CBSE standards is equally valid. The need for a common syllabus, prepared in consultation with State governments, has been expressed. Of the 49,990 seats for the Bachelor of Medicine, Bachelor of Surgery (MBBS) course, 25,330 are in government medical colleges and 24,660 in private colleges. Admission to government-run colleges is conducted through the All India pre-Medical Test (AIPMT) and the common entrance test (CET). Private medical colleges have their own system of examination and admission.
The entrance examination is conducted in English and not in any regional language. It has also been pointed out that the course is taught in English. However, the concern raised is that since the syllabus for the entrance test is tailored to CBSE standards, children who have studied in the State boards will find it difficult to clear the examination. However, there is unanimity that the standards of medical education cannot be compromised, whether at the entry level or subsequently.
The April 27 judgment was in consonance with a May 2 judgment of the Supreme Court ordering the formation of a committee comprising former Chief Justice of India R.M. Lodha, former Comptroller and Auditor General of India (CAG) Vinod Rai and the Director of the Institute of Liver and Biliary Sciences to oversee the Medical Council of India (MCI) and directing the MCI to seek prior approval of the committee for all policy decisions. It also endorsed the Parliamentary Standing Committee’s report on the functioning of the MCI, which was submitted to the government in March 2016. The report found medical education to be at its lowest ebb and suffering from “total system failure due to corruption and decay”. The Supreme Court intervened as the government had not acted upon the report submitted to it.
Disposing of a clutch of appeals by private medical colleges of Madhya Pradesh challenging the law regulating admissions and fees, the judgment, authored by Justice A.K. Sikri, held that educational institutions should not be set up with the objective of making profit and that the government was empowered to regulate admissions by prescribing a CET or NEET and also “forbid capitation fee and profiteering”. The underlying principle, as elucidated in an order of the Constitution Bench, was that education was not a “business” but a “noble activity” aimed at empowering people.
The April 11 and 27 judgments overruled the 2013 order of a three-judge bench, which gave minority institutions the right to conduct their own admission process ( CMC Vellore vs the Union of India ). The 2013 judgment, which was a majority judgment (with one judge giving a dissenting view), arose in the context of a petition challenging the NEET on grounds such as federalism and the right of minority institutions to conduct their own admissions.
Ironically, all these efforts to correct the anomalies in the admission processes for medical education and by default reform the medical and health architecture in the country came to nought when the Central government issued an ordinance on May 24 staying the implementation of the NEET for one year on the grounds that several State governments had expressed reservations about conducting the test. The ordinance amending the Indian Medical Council Act, 1956, inserted a provision laying down that a uniform entrance examination to all medical institutions at the undergraduate and postgraduate levels shall be conducted through such designated authority in Hindi, English and such other languages provided that notwithstanding any judgment or order of the court, the provisions of this section shall not apply in relation to the uniform entrance examination at the undergraduate level for the academic year 2016-17 for State government seats, in government medical colleges and private medical colleges. Union Urban Development and Parliamentary Affairs Minister M. Venkaiah Naidu gave the assurance that the NEET-UG would be deferred for a year, and the government issued an ordinance to this effect.
Tamil Nadu’s protest Tamil Nadu had challenged the NEET in the Supreme Court and its Chief Minister took strong objection to it on the grounds that it would affect the rights of the State, its policy initiatives and socio-economic objectives. Following the 2013 order staying the NEET, the State government had expressed objection to any “purported attempts by the GOI to review the judgment of the SC [Supreme Court], seeking a reintroduction of the NEET or by introducing it in any other name or manner as it infringed on the State’s rights, admission policies to medical institutions in Tamil Nadu”.
The ordinance was challenged by the Right to Information (RTI) activist Anand Rai on the grounds that the Central government had accepted the need for a unified uniform examination for undergraduate and postgraduate courses and had even provided a schedule to the court in another writ petition ( Sankalp Charitable Trust and Another vs the Union of India ) filed before the court. The ordinance reflected a contradiction in the government’s stand as the examination was to be held within eight weeks according to the schedule given by the government. The vacation bench of the Supreme Court did not stay the ordinance on the grounds that it would create confusion in the minds of students. State governments and private medical colleges were once again free for one year to conduct the examinations in any manner they deemed fit and charge fees, including capitation fee, as per their policies.
The National Coalition for Reforms and Restructuring of the MCI, a recently formed group of well-known physicians and civil society networks—such as the Indian Doctors for Ethical Practice, the Punjab Medical Council, the Indian Journal of Medical Ethics, the Jan Swasthya Abhiyaan, the Forum for Medical Ethics, the Medico Friends Circle, and the Indian Doctors for Peace and Development—criticised the decision to defer the NEET, saying it would give the “medical mafia” sufficient time to manipulate the admission process. A statement issued by it said: “This is a pressure tactic by private medical colleges and other interested parties who want the capitation fee to continue. It is learnt that nearly 80 Members of Parliament have direct interest in private medical education.” The coalition said the NEET was a “bold step to end admission to medical colleges using corrupt means and money power”.
The background
Until 2013, the CBSE had conducted the AIPMT/All India Pre Dental examinations for admission to the MBBS and Bachelor of Dental Surgery (BDS) courses. A notification issued in December 2010 by the MCI and the Dental Council of India (DCI) laying down the norms for a common NEET was legally challenged ( CMC Vellore vs Union of India ). Striking down the notification, the Supreme Court held that “we also have no hesitation in holding that the Medical Council of India is not empowered under the 1956 Act to actually conduct the NEET”. The MCI filed a review petition on October 23, 2013, and so did several others. On April 11, 2016, a Constitution Bench recalled the July 18, 2013, judgment restoring the status quo in the matter. On April 27, the five-judge bench upheld the validity of the CET by State governments and the NEET by the Central government and directed all associated with the conduct of the examination to extend all support to the CBSE in conducting the NEET.
Petitioners challenging the government ordinance said the court ruling had cleared the decks for conducting the NEET in two phases for the academic year 2016-17 as per the schedule proposed by the CBSE. On May 1, phase one of the NEET was conducted and six lakh students appeared for the examination. The court also ruled that private colleges would not be allowed to conduct separate examinations for medical admissions. Likewise, the State governments’ plea to conduct separate entrance examinations was rejected and the court ruled that students could get admission to the MBBS or the BDS course only through the NEET. Following complaints that students were not given adequate time to prepare for the test, the court agreed that the second phase of the NEET would be conducted on July 24. It was decided that only one examination would be conducted for admission to medical colleges, and that would be the NEET.
Reform medical education The Parliamentary Standing Committee report, despite its narrow purview of the functioning of the MCI, had outlined some broad concerns facing medical education. It noted: “Since the Medical Council of India is mandated to play a pivotal role in regulating medical education and practice in the country, the committee decided to holistically examine its role and functioning with the ultimate aim of suggesting veritable solutions to the inadequacies that are currently plaguing our medical education and health care delivery systems.”
The Standing Committee’s prescriptions for improving access to health care were considered problematic and its recommendations were confined to suggesting reforms in the bureaucracy within the MCI with a greater role envisaged for the Central government. But the Standing Committee, on the basis of representations received from various groups in the health care sector, concluded that there were serious issues concerning medical education. It stated that it was not only that the MCI had failed in discharging its mandated responsibilities, the absence of proper screening and admission procedures in private medical colleges was a problem. Its other concerns included the prevalence of capitation fees in private medical colleges in flagrant violation of the law, barriers to expansion of medical education, the lack of a robust accreditation system for medical education, gross inequity between rural and urban India in terms of availability of health care services, ethical issues, need for reforms in the regulatory framework of medical education and practice, over-investigation, and the overtreatment in private hospitals and inadequacy of self-regulatory processes for the medical profession.
More importantly, it said that there was a need for a common entrance test for admissions to MBBS and postgraduate and super-specialty medical courses. The committee observed that the “main objective of the regulator of medical education and practice in India is to regulate the quality of medical education, tailor medical education to the health care needs of the country, ensure adherence to quality standards by medical colleges, produce competent doctors possessing requisite skills and values as required by our health system and regulate medical practice in accordance with the professional code of ethics. The Medical Council of India, when tested on the above touchstone, has repeatedly been found short of fulfilling its mandated responsibilities. The quality of medical education is at its lowest ebb; the current model of medical education is not producing the right type of health professionals that meet the basic health needs of the country because medical education and curricula are not integrated with the needs of our health system; many of the products coming out of medical colleges are ill-prepared to serve in poor resource settings like primary health centre and even at the district level; medical graduates lack competence in performing basic health care tasks like conducting normal deliveries; instances of unethical practice continue to grow due to which respect for the profession has dwindled. Medicine deals with human life. Regulators are, therefore, required to have the professional excellence and moral authority to address complex issues related to content, standards, quality, competencies and skills of medical education and practice.”
Standards of merit It is equally ironical that standards of merit do not seem to apply in cases where medical colleges charge capitation fees or reserve seats in the management quota or even admit students on the basis of recommendations. Critics of affirmative action often fail to point out these glaring hypocrisies in the system that allow in effect a system of reservation for those who can pay their way through.
The Supreme Court’s intervention in the matter by prescribing a centralised examination system was a small step in correcting the abuse of money power in the field of medical education. The ordinance did not face resistance perhaps owing to the clear warning issued by some senior Ministers in the government to the judiciary not to cross the “Lakshman rekha”. That the authors of the Parliamentary Standing Committee report did not find it important to intervene in some form is an indication of their commitment to the issue of reform. The only casualty in this case has been the people of India.
