Doctors by merit, not privilege
India is the only country that authorises, as official policy, the sale of medical seats by private medical colleges, implicitly accepting the principle that the ability to pay, and not merit, is what counts. Further, in the absence of any system of third party certification by way of an entry or, more importantly, an exit exam — which could guarantee the qualities and competencies a doctor must possess before starting to practice — many medical colleges are producing quacks. The tragedy is that we all know about it.
The issue is not just about illegal capitation fees that range from Rs.50 lakh to Rs.1 crore for a MBBS seat. The process of admission is itself flawed with a walk-in system for those with money but for the others, it is a harrowing tale of expensive tuitions and writing 15 to 20 examinations across the country — a process that once again excludes and deters several.
In order to reduce the stress of multiple examinations, make it more equitable and ensure minimum levels of competence, having the National Eligibility-cum-Entrance Test (NEET) as a qualifying requirement for admission has been a long-standing recommendation of experts. It was reiterated in 2010 by the Medical Council of India (MCI), inspired by rapidly deteriorating standards of school education.
The delay in implementing NEET was because of a lack of political will and the growing clout of private medical colleges in a neo-liberal environment that has encouraged a deadly cocktail of money power and political muscle. It is creditable that despite pressures, the MCI conducted NEET in 2012, for 90,000 aspirants.
Defying the MCI mandate on regulating entry into medical colleges, about 90 private colleges held their own examination and, on specious grounds, successfully obtained a stay from the Supreme Court. On May 13, the Supreme Court issued an interim order, making NEET voluntary and permitting the private colleges to go ahead with admissions based on their own examinations. For the harried students, it was Black Monday.
Archaic and outmoded rules, regulations and eligibility conditions requiring a capital base of more than Rs.150 crore have made the establishment of medical colleges a business proposition. Combined with no incentives for quality education, there has been a twofold impact: 1. commercialising the medical profession, where “recouping” the investment is the prime concern for the investor and graduating doctor alike; and 2. an aggravated shortage of doctors in three ways: 15 per cent of those in the Non-Resident Indian quota within the 50 per cent management quota do not practice in India; of the remaining 35 per cent, many do not practice, migrate abroad or establish themselves in cities for better incomes; and, poor training makes many “unemployable” as amplified in a provider survey by Jishnu Das in Madhya Pradesh which found a marginal difference in the practices of “qualified” doctors and quacks. Clearly, the commercialisation of medical education is one of independent India’s biggest mistakes.
Therefore, the solution of “flooding the market with doctors by opening more medical colleges” to contain the menace of capitation fees without in the first instance, overhauling the regulatory framework related to quality of instruction, faculty development, better salary structures and banning private practice, etc has little merit.
Issue of quality
There are no short cuts or easy solutions to what has become a highly political issue. If people’s health really matters for this government and if India is to stay competitive globally, it can no longer look the other way. It has to exercise its constitutional authority to bring in much needed institutional reform to clean up the mess, just as it did in 2010 by replacing a corruption-ridden MCI with a board of governors by way of an ordnance.
In the same year, the ministry also drafted a bill to establish a National Commission for Human Resources for Health (NCHRH) to address the issue of quality by balancing the three critical functions of the profession: a) curriculum — what is to be taught and for how long; b) accreditation — who is to teach and in what manner; and c) ethical practice — adhering to the best interests of patients.
While the first two aspects were placed within the domain of a nominated body of experts, ethical medical practice was to be ensured by an elected body of the MCI. A distinction between nomination and election was made keeping in view the professional expertise needed to address complex issues related to content, standards, quality, competencies and skills as required by the country. Such expertise has to be sought and is not thrown up through electoral processes. It is for this reason that in most countries such as the United Kingdom, regulators are selected by the Public Service Commission based on merit and suitability. In addition, the U.K. Medical Council also has patient groups, student representatives and civil society activists as members of the Medical Council. Such openness and transparency is the only effective antidote to an indiscriminate abuse of power.
Focus on the regulator
In October 2012, the Parliamentary Standing Committee returned the NCHRH Bill to the government to re-examine three major concerns: 1. States’ autonomy and potential violation of federal principles; 2. excessive bureaucratisation and centralisation, and 3. faulty selection procedure of regulators, providing scope for abuse. Rather than seizing the opportunity to come up with a better draft, the ministry has, for the third time, reconstituted the board of governors with a retired Directorate General of Health Services as chair.
It is believed that the main purpose of the reconstituted body is to oversee the elections to the Board of the MCI. If true, this is disheartening. The MCI is the regulator for medical education and practice just as the Reserve Bank of India is for financial institutions or the Election Commission of India for elections. Regulators cannot be elected on popular mandate — they have to be invited by the government for their professional eminence and moral authority. The MCI has to discipline and police the profession, more so on account of the extensive market failures that characterise it. Elected persons are compromised individuals and cannot do the task effectively. We have seen how disastrous our experience has been with an elected body; within the decade 2000-2010, it was set aside twice, once by the Supreme Court and the second time by the government by way of an ordnance. No other regulatory body has suffered such humiliation.
Since medical education is in the concurrent list of the Constitution, the Central government needs to leverage that power to bring in some discipline before permitting any more colleges to be established. The time has come to strengthen the regulator first by having the MCI Board freed from the clutches of doctors to include all stakeholders and have the members appointed through a rigorous selection process by an autonomous body like the Union Public Service Commission. This will end the nomination process of the ministry and the consequent conflict of interest. Once appointed, the regulator can be allowed to enforce its own rules and regulations.
The government needs to attend to a range of reforms from: appointing a tariff committee, indicating the right quantum of fees to be charged and legally enforcing the same; providing autonomy to medical colleges to stimulate excellence and innovation; constituting a committee of experts under the chairpersonship of a senior politician to examine some of the contentious issues, including the frequently made suggestion to nationalise private colleges, and appointing an advisory committee to undertake some of the critical functions of curriculum change and accreditation pending the establishment of a body like the NCHRH, which in today’s circumstances may take not less than three years. What is required is a non-negotiable, high priority concern for patient welfare and safety by focusing on the quality of doctors being produced, in sufficient quantity of the skill mix.
In conclusion, sorting out the mess in medical education requires a consensus across the political spectrum. Any shifts in the status quo will be bitterly opposed, so deeply entrenched are the vested interests. But the time has come for the government to act as the acute shortage in human resources is the main barrier to achieving universal health coverage. The more the delay in addressing the critical challenges facing human resources for health on grounds of political expediency, the greater the social, political and financial costs this country will have to bear in the years ahead. Prudence lies in stemming the rot by decisive action and before it is too late.
(Sujatha Rao is a former Secretary, Ministry of Health & Family Welfare. E-mail: firstname.lastname@example.org)