After an aborted attempt during the previous Lok Sabha, the central government has made a fresh bid to replace the controversial Indian Medical Council (IMC) with a National Medical Commission (NMC) to regulate medical education and practices in India. While the Medical Council of India (MCI) was an autonomous body with two-third of its members (160 plus) being directly elected by the medical fraternity, the new one would have 25 members with no directly elected member.
Earlier in the month, the government had passed the Indian Medical Council (Amendment) Bill of 2019 to supersede the IMC on the ground that it had failed to discharge its duties and indulged in corrupt practices.
What the Bill provides
The National Medical Commission Bill of 2019 proposes to have four autonomous boards to take care of its different functions:
(i) Under-Graduate Medical Education Board to set standards and regulate medical education at undergraduate level
(ii) Post-Graduate Medical Education Board to set standards and regulate medical education at postgraduate level
(iii) Medical Assessment and Rating Board for inspections and rating of medical institutions and
(iv) Ethics and Medical Registration Board to regulate and promote professional conduct and medical ethics and also maintain national registers of (a) licensed medical practitioners and (b) Community Health Providers (CHPs).
The CHPs are a new class of medical practitioners to be given licenses to practice modern medicine at mid-level to those "connected with modern scientific medical profession", the criteria for which would be specified later. Their number would be one-third of the total number of licensed and registered medical practitioners.
As for admissions and licensing, the Bill provides for a National Eligibility-cum-Entrance Test (NEET) for admission to all undergraduate and post-graduate "super-speciality" medical education, while providing for another one, National Exit Test (NEXT) for granting "license" to practice and admission to postgraduate "broad-speciality courses".
So far, all admissions are through the NEET and no licensing is required for practice but a medical practitioner has to register with a state medical council for this.
The Bill also proposes for the NMC to "frame guidelines for determination of fee and other charges" for 50% of seats in private medical institutions and deemed to be universities.
Currently, state governments determine fees for 85% of seats in such institutions and the rest are left for the management.
Other powers of the NMC include permission to establish new medical colleges, start post-graduate courses, increase the number of seats, recognition of medical qualifications in and outside India etc.
Reasons for change
The Statement of Object and Reasons of the Bill says the IMC had failed to keep pace with time and various bottlenecks had crept into the system with serious detrimental effects on medical education and, by implication, on delivery of quality health services.
A Parliamentary panel which had looked into the matter had recommended restructuring and revamping of the regulatory system of medical education and practice.
It had also recommended separation of functions by forming four autonomous boards and appointment of regulators through selection, rather than election.
IMA's four major concerns
The Indian Medical Association (IMA) - the apex body representing the medical fraternity in India which had earlier opposed the government takeover of the MCI has strong reservations about the NMC too. Dr RV Asokan, secretary-general of the IMA, list four major ones.
The first one is over the CHPs being allowed to practice modern medicine. The Bill does not define who they are or what qualifications they hold and yet they are to be given licenses to the extent of one-third of the total number of licensed medical practitioners in India.
Dr Asokan says this may open the door for persons with inadequate training in modern medicine to practice, putting patients at risk and lowering standards of healthcare.
He fears those with some connections with modern medicine like pharmacists, practitioners of other systems of medicines with a bridge course, ophthalmologists and even existing healthcare workers at the primary health centres may get licenses to practice modern medicine.
"They may not have sufficient background in the study of anatomy, physiology or pathology etc. which form the basis of modern medicine. Besides, their significant presence will endanger patient safety and dilute healthcare in the country, especially in the rural areas", he comments.
Dr Asokan points out that about 68,000 medical graduates pass out of more than 500 medical colleges every year. As only 23,000 of them qualify for post-graduation courses, the rest (45,000) end up looking for jobs or loiter around coaching institutions.
"Here the government is providing an opportunity for unqualified or partially qualified persons to practice while the qualified ones are available and frustrated because of unemployment", he observes, adding that this is another attempt at lateral entry for the unqualified or partially qualified that the government had proposed in an earlier Bill but was forced to withdraw due to protests.
The IMA's second major objection is to the proposed National Exit Test (NEXT) for giving both licenses for practice (to those who have already cleared the MBBS exam) as well as for admission to post-graduate "broad-speciality courses".
Dr Asokan says the two objectives can't be reconciled since the level of knowledge and training required for both are very different. While for practising medicine, a minimum level of competence is required (passing the MBBS), admission to post-graduate courses calls for a higher level of competence and only the cream of the profession gets selected.
"In the last NEET exam, only 70,000 of 1.43 lakh candidates qualified for post-graduate courses. What will the rest 73,000 qualified MBBS doctors do? They will not be licensed to practice, thus defeating the very objective of providing greater number of trained health manpower", he comments.
The third major objection is to "frame guidelines" to determine fees and all other charges for 50% of seats in private medical institutions and deemed to be universities (the MCI did not have such powers).
Dr Asokan says at present state governments "regulate" fees for 85% of such seats and the rest (15%) are for the management to decide. "Now the NMC proposes to only frame guidelines for regulating fees for 50% of seats.
This is further dilution of the power to fix fees where all 100% of seats may be available for the highest bidder, thereby increasing the cost of medical education. It is a reservation for the rich", he says.
The IMA has another major objection. This is about the power the Bill gives to the central government to give policy and other directives to the NMC and its autonomous boards which will be binding and final.
This is contradictory to the very concept of autonomy of the four boards. The central government has also been empowered to give directives to state governments for implementing provisions of the Bill, which will also be binding, reflecting the anti-federal character of the Bill.