India recently passed National Medical Commission Bill which has outraged doctors and they see it something which will encourage quackery. But public healthcare advocates consider it as one of the biggest reforms as they see it as the first move towards achieving Universal Health Coverage in India, reports Deepika Khurana.
By Deepika Khuaran
India is world-famous for its doctors and it produces some of the world’s best surgeons and physicians. There are more medical colleges and teaching hospitals in India than anywhere else in the world. But medical education faces its own extremely pressing challenges. Recently India’s parliament passed the National Medical Commission (NMC) Bill 2019 despite facing major opposition from the doctors.
With this reform, the medical education system in India is about to witness a drastic change as the bill seeks to address shortage of doctors in the country and reshape media training. If the Bill becomes a law, the Medical Council of India (MCI), an autonomous body with two-third of its members (160 plus) directly elected by the medical fraternity will be replaced with the NMC, a 25 member body.
According to the government, the NMC Bill will regulate all aspects of medical education, profession, and institutions in India. While medical fraternity is aghast and has been opposing the bill since its initial inception in 2017, public health advocates consider this reform as a welcome move.
“NMC Bill basically hopes to reform what was the moribund state of medical education in India. Let’s not get into taints and deficiencies with which MCI has been associated with because the Supreme Court of India as well as the Parliamentary Standing Committee on Health – all have expressed great displeasure at the way MCI was functioning,” said eminent cardiologist and Public Health Foundation of India (PHFI) president Padma Bhushan Prof K Srinath Reddy.
The bill seeks to annul the Indian Medical Council Act 1956 in the wake of allegations of corruption against the 63- year-old MCI. “The Bill is in response to the shortage of doctors we are facing, to increase the number of medical colleges, to reorient some of the training programs to the national needs and also to bring in greater degree of transparency into the whole administration of medical education,” said Prof Reddy.
WHAT IS NMC BILL?
The National Medical Commission Bill of 2019 proposes to have four autonomous boards to take care of its different functions. This includes i) Under-graduate medical education board and post-graduate medical education board that will look into the regulation of medical education at their respective levels. ii) Medical assessment and rating board that will take charge of inspections and ratings of medical institutions. iii) Ethics and medical registration board to regulate professional conduct and medical ethics besides maintaining national registers of licensed medical practitioners and Community Health Providers (CHPs).
The CHPs are a new class of medical practitioners being introduced. “We must recognise that doctors are important but only a small part of the total health workforce,” said Prof Reddy.
According to Prof Reddy, the former head of the Department of Cardiology at the AIIMS, New Delhi and the Adjunct Professor of Epidemiology at Harvard, when it comes to providing healthcare, there are many other categories involved – nurses, allied health professionals, and then there is a passing reference to the introduction of CHPs in the Bill. “Its a category which is still not fully defined but, yes, there’s a recognition that we need many other categories other than doctors.”
CONCERNS OF DOCTORS
One of the main points of disagreement between the doctors and government is that the bill provides licensing to 3,50,000 non-medical persons, or community health providers (CHPs), to practise modern medicine. Doctors warn that the section will fuel quackery, and lead to untrained providers offering treatment to patients.
The Indian Medical Association (IMA) – the apex body representing the medical fraternity in India has expressed strong reservations. The IMA believes that the newly constituted NMC will promote crosspathy and medical pluralism as is evident from Section 50 of the Bill. It is expected to give rise to ‘hybrid doctors’ which will have a direct impact on the quality of care that will gradually be lost for generations to come.
“Why should we follow Sub-Saharan states in the concept of Community Health Worker Providers or China in producing barefoot hybrid doctors?,” asks Dr. RV Asokan, Secretary-General of the IMA. “ Providing licence to practise and prescribe to a non-medical quack is in effect a license to kill.”
He said that the Bhore Committee (set up under Sir Joseph Bhore) in 1946 envisaged that the minimum qualification to practise modern medicine in India is MBBS. While highlighting that India has produced some of the finest, trained and sophisticated doctors, Dr. Asokan added, “Indian doctors form the backbone of clinical services in western countries, including the US and UK. But we owe it to the quality of education that’s available in our country. So, as a matter of fact, India is in the frontier of modern medicine.”
Echoing similar concerns, Dr. Vipin Tyagi, a Consultant Urologist, Robotic and Kidney Transplant Surgeon at Sir Ganga Ram Hospital, New Delhi said that more than 70% of his patients come from rural India and the picture they paint is a grim reality. “I face it almost every day. Most of my patients come to me after seeking treatment from quacks. Some are lucky to reach us on time but for some, it gets too late.”
He further added, “For treatment or complete cure, the patient needs to be diagnosed properly and on time. No doubt, Community Health Providers (CHP), with their little knowledge, may be able to provide symptomatic relief, but wrong diagnosis and untimely treatment can prove to be life-threatening for patients at times.”
He cited a tragic incident that was reported from Nampally, Telangana earlier this year where thirty-four infants were wrongly given an opioid painkiller tablet instead of paracetamol.
“It resulted in the death of two children,” Dr. Vipin Tyagi said. “The drug was prescribed by a non-medical staff member at an urban healthcare centre. Apparently, he confused the similar packaging of the two medications.”
Dr. Asokan points out that today after 70 years of independence, we have 532 medical colleges with 71,993 MBBS medical seats available; of which 247 medical colleges are in the government sector, while 250 are in the private sector. And, about 38,013 MBBS seats are in government medical colleges and 33,980 are available in private medical colleges.
“Number of Primary Healthcare Centres (PHCs) and Community Healthcare Centres (CHCs) in the country has stagnated for decades. There has been no creation of new posts either. Doctors are recruited on ad hoc basis for a pittance,” said Dr. Asokan.
Furthermore, he added that out of 71,993 doctors coming out of medical colleges in India every year, around 23,000 MBBS graduates get PG seats. Whereas, around 45,000 doctors remain unemployed and underemployed who keep making regular attempts, year after year, to clear NEET exam for a PG seat.
“At any point of time, around 1,50,000 MBBS graduates in our country remain unemployed,” he said.
Doctors and members of the medical community are worried that individuals with inadequate training in modern medicine will put patients’ lives at risk.
“Rather, the government should gainfully employ these fine MBBS graduates. Infact, IMA can help the government to employ these medical graduates in rural areas; provided they are recruited through a public service commission and are given regular government salaries and promotions,” said Dr Asokan.
On another concern regarding scraping NEET, which is the current PG entrance exam and replacing it with a common exit or licensing exam called National Exit Test (NEXT), Dr Asokan added, “How can one exam do justice for both?”
Dr. Asokan is of the view that the two objectives can’t be reconciled since the level of knowledge and training required for both are very different.
THE OTHER SIDE
Government and public health advocates, to the contrary, find the Bill in accordance with India’s Universal Health Care (UHC) system. According to Kiran Mazumdar-Shaw, CMD Biocon Limited and Chairperson of the Indian Institute of Management, Bangalore, the NMC is a well thought out policy that aligns with new health care insurance plan called Ayushman Bharat and the need to provide affordable universal healthcare.
“National Medical Commission’s plan to permit Community Health Providers to prescribe modern medicine at Primary Healthcare Centres is the only way to bridge the doctor deficit in our country,” said Mazumdar-Shaw.
According to WHO there is one government doctor in India for every 10,189 people or a deficit of 600,000 doctors and the nurse: patient ratio is 1:483, implying a shortage of two million nurses. India’s government spent just 1.4 percent of the country’s gross domestic product on health care.
“A short training-cum-certificate program should suffice to prescribe oral drugs like antibiotics, analgesics, hypertensive drugs and anti-diabetics. This could be further strengthened with periodic visits by qualified doctors to provide continuous training and verification of prescription practice,” she said. “Community Health Providers are a valuable resource that must be leveraged.”
While negating doctor’s agitations and protests, Mazumdar-Shaw added, “Doctors who are resisting this move ought to volunteer to practice in rural PHCs or provide solutions without which they should not deny rural populations access to medicines.”
The Bill has been proposed taking cognisance of the fact that several rural areas lack adequate staff or facilities at the local health centres.
“Who said everything will be treated there. You are only accessing and treating a certain set of conditions which can be further referred,” said Prof Reddy. He further added, “It’s not that patients can’t go elsewhere. It’s not that people are going to get imprisoned in a subcenter. But, we got to understand that right now very few services are available for our rural population.”
Besides imparting some basic training and skillset, Community Health Providers can be further equipped with technology. “Technological know-how will improve their diagnostic abilities and if need be, they can always consult doctors. And, the Bill doesn’t say that all medical conditions will be treated by non-doctors. But, at the same time, we must not say that no condition can be treated there,” he stated. “So we have to invest in Community Health Providers.”
While mentioning the category of physician assistants, Prof Reddy said that this category of the health workforce is trained for four years. They are used extensively in some countries abroad; the US in particular. In India too, some institutions in Tamil Nadu and West Bengal are producing this category. “If you ask me, four years is not a short period of training,” he said.
These physician assistants usually function under the supervision of doctors in hospitals. “But they are also equipped to handle primary healthcare at the subcenter level. So, everything depends on the nature of training.”
Prof Reddy is fairly optimistic about the introduction and addition of this new category of the health workforce. According to him just as doctors and nurses are recognised in our country, similarly we can have another set of category that’s trained and tested.
“Between quacks or totally untrained, this will be a level of people who are not trained at the level of being full-fledged doctors,” he said. “But, at least, they will be better than quacks and will have some set of defined skills.”
Highlighting the basic architecture that can be critical for the success of the Bill, Mazumdar-Shaw said that Electronic Medical Records (EMR) on a digital health platform should be considered. Infact, Biocon Foundation has piloted Digital PHCs in Rajasthan and Karnataka and the concept has been successful.
“The NMC must focus on digital healthcare to leapfrog from no healthcare access to basic universal healthcare,” said Mazumdar-Shaw. “A combination of electronic medicines compendium, telemedicine and medtech can do wonders to make it a success.”
