Shri. Ram Gopal Yadav
Parliamentary Standing Committee on Health,
Government of India, New Delhi.
Subject: Suggestions/Objections to National Medical Council Bill, 2017 (hereinafter referred to as “NMC Bill”)
Introduction:- The idea of reforming and revamping the MCI took root in the Independence Day speech of former Prime Minister Manmohan Singh in 2009. The vision was to replace the MCI with an overarching National Commission for Human Resources for Health with four verticals looking after the four different aspects of regulation – Undergraduate, Postgraduate education, Accreditation and Licensing and Ethical practice. It was to provide platforms for cross consultation and coordination between the disciplines and medical and non-medical personnel. In 2013, the Parliamentary Standing Committee (PSC) returned the ambitious Bill with three terse observations:-
1 The states’ autonomy and potential violation of federal principles;
2 Excessive bureaucratization and centralization; and
3 Faulty selection procedure of regulators, providing scope for abuse.
Ironically, all these observations pertain to the current NMC Bill as well. The new NMC was approved by the cabinet and placed for discussion in the Lok Sabha on January 2, 2018. When the Bill came to light, it generated an unprecedented response – a one-day strike by nearly three lakhs doctors and protests from all sections – doctors, health activists, former policy makers, academicians and so on, forcing the Central government to refer it to the Parliamentary Standing Committee for further deliberation.
Despite nine years of confabulating, the National Medical Commission (NMC) Bill has the danger of having outcomes worse than the Indian Medical Council (MCI) Act. The Indian Medical Association (IMA) and doctors at large have expressed outrage at some of the provisions in the Act.
1. Faulty Preamble and intentions thereof:-
The very preamble of the NMC Bill states that “principle of the “regulated” electing the “regulator” is flawed and creates a conflict of interest and therefore MCI should be discarded”. The basic argument that only those selected and nominated can govern or regulate is clearly indicative of desire of a totalitarian Government to subjugate professionals to toe its line or face the wrath. If today this happens to medical professionals, it is bound to repeat itself for all other professionals whether they are architects, cost and work accountants, journalists, advocates ,chartered accountants or even the judiciary which lays down procedure to regulate themselves.
We live in a parliamentary system where despite allegations of corruption against many parliamentarians we do not junk and reject the democratically elected representatives to seek and select a dictator.
2. Over Centralization
The over centralization of the NMC and the near control over it by the Central government, ranging from appointing all the 77 members for the various bodies; being the appellate for a variety of routine technical matters rejected by the autonomous bodies and the whole NMC such as, granting permission to set up colleges; granting exemptions to criteria; approving courses; setting aside any punishment against a doctor found negligent; allowing doctors trained abroad to do surgery and practice without having to go through any screening or taking the licentiate examination; recognizing degrees and qualifications; and finally having powers to issue directions to state governments and the NMC to comply with any orders it seeks to issue, not to speak of setting the Commission itself aside.
Such wide-ranging powers that will be exercised by the central ministry rob not just the federal nature of the law and reduce the NMC to an advisory role. In fact, the whole nine-year battle for revamping the MCI was mainly centered around the growing politicization of medical education with the powers introduced in the Act in 1992 that made it mandatory for MCI to take give prior approval for starting a college, a course and student strength. This is one grouse that medical professionals opposing the Bill have.
3. Central Govt. empowered to issue directions:-
As per section 44(1)(2) of the Bill, although, autonomy is expected to be a hallmark of the NMC Bill, 2017 and the Boards there under are called as, “Autonomous Boards” in reality the same is a misnomer as in the said proposed Bill the Central Govt. would be entitled to give directions to the Commission and autonomous boards on all the questions of policy which would be binding for the commission and autonomous Boards to comply. Further, it is clearly stipulated that the decision of the Central Government. whether question is one of the policy or not, would be final and is not open for any discussion and deliberation whatsoever.
As per the section 45 of the Bill, the Central Government would be within its rights to give such direction it may deem necessary to the State Government for carrying out all or any of the provisions of this Act and the State Government shall comply with such directions is also undermining the authority of the State Government which is inconsistent with the cardinal principles governing the federal polity as stipulated in the Constitution of India. Similarly as per section 10(1)(f) of the Bill, State Medical Councils also have to comply all such directions/policy of the National medical commission.
4. Undemocratic constitution of the boards proposed under the bill
As per section (4) of the Bill, Composition of the National Medical Commission, which will have an effective membership of 25 of which only 5 members(Part Time) will be elected.
As per section (11) of the Bill, Composition of an Advisory Body to be known as the Medical Advisory Council. Totally Medical advisory council shall consists of about 60 members. All are nominated members.
As per section (16) of the Bill, Composition of 4 autonomous boards to be known as the UGME Board, PGME Board, MAR(Medical Assessment and Rating) Board and EMR(Ethics and Medical Registration) Board. Each board consists of 3 members only and all these members will be nominated by Central Government. Totally these four boards shall consists of 12 members. They will constitute further sub committees to assist them.
As such it is evident that the proposed commission will have 20% elected members (part time) and 80% nominated members. It is for this reason it will not have a desired ‘representative character’ with reference to ‘elected and nominated / appointed members’ whereas present Medical council of India has 75% elected members and 25% nominated members.
Small and medium healthcare establishments provide more than 70 % healthcare needs of the country. They did not have any representation in the MCI which was institution dominated and neither is it represented in the new National Medical Commission. This is fraught with danger of ignoring the ground realities of the medical profession in India, its needs and hence the reforms so passionately sought to be brought will remain on paper. Also modern scientific medicine has divided itself into specializations and sub specialization. Representation of various specialties is essential to prevent overlooking specific areas and their needs.
5. Non-Experienced Controllers:-
The doctors who have experienced the medical education system, gone through residency pains and faced the scorching furnace of clinical practice only are best suited to understand the needs of the profession and to regulate it by being part of MCI / NMC. Chairman Niti Ayog and Secretary Health may be good administrators in their own right but cannot be expected to understand the requirements of the profession. What is being attempted through National Medical Commission Bill is somewhat akin to asking IAS officers to lead the Indian Army.
Bureaucrats whether medical or non medical remain in their ivory towers in total disconnect of the ground realities and in the field of healthcare their desire to control medical education as well as practice of medicine through the NMC Bill will be disastrous for the country.
6. Discretionary Powers for relaxing prescribed regulatory conditions:-
As per section 29(b) of the Bill, the MAR board is to look into ‘whether adequate faculty and other necessary facilities have been provided to ensure proper functioning of the medical college or would be provided within the time limit specified in the scheme’ while granting permission to start Medical college or PG courses. This vests the board with a wide discretionary power to accord approval on a hypothetical assumptive presumption that the stipulated minimum requirements would be completed in due course of time. This by itself entitles the MAR Board to permit learners to be taught and trained in compromised conditions impacting and prejudicing the desired quality of medical education. Added to this is the provisio 2 ,Section 29(d) of the Bill, the MAR Board can relax the criteria for opening of the medical colleges at its discretion with the previous approval from the Central Government which yields not only a wide authority but also provides adequate scope for availing the discretion for extraneous considerations. More so the regulatory stipulations which are mandatory in nature and binding in character cannot be open for any concession or condonation vide discretionary authority. The said discretionary authority is not only vested with the autonomous board but also is with the Central Government as well. Such dual / double discretions to waive the applicability of statutory stipulations governing prescribed requirements per se bad in the eyes of the law and end up in providing ample scope for a free flowing corruption to dwell and get deep rooted.
7. Imposition of Penalty:-
As per section (26)(1)(f) of the Bill It is provided that MAR Board take such measure, including imposition of monetary penalty, against a medical institution for failure to maintain the minimum essential standards specified by the UGME Board or the PGME Board, as the case may be.
The material point for consideration is that all the three monetary penalties are not to be less than one half and not more than ten times the total amount charged by such institution for one full batch of students of undergraduate course or postgraduate course as the case may be. It yields such wide period and discretionary power to the Board and in the name of charging fine the permissibility of the period turns out to be substantial before the closure is invoked meaning that during the impending period the learner would be taught and trained in compromised ambience resulting in impoverished teaching and ending up in generation of half-baked health manpower, which would be ill conducive to the healthcare delivery system.
8. NON-SECURITY OF THE PRESENT DAY DOCTORS:-
Besides regulating MBBS doctors, it should also be function of MCI / NMC to look after their interests and welfare as is a part of objectives under Indian Advocates Act mandated Bar Council. This is an omission which should be corrected ASAP.
9. FEES and the Management quota
As per section (10) of the Bill, the functions vested with the Commission under the Act are generic and cosmetic in character. There under it is to exercise appellate jurisdiction with respect to decisions of the autonomous boards.
As per section 10(1)(i) of the Bill, commission would be framing guidelines for determination of Fee in respect of such proportion of seats not exceeding 40% in the private medical institutions. This operationally means that the fee regulation would be limited to a maximum of 40% seats in the private medical institutions, which is difficult to understand as to why such a ceiling and further more it could be anything from nil up to 40% which is paradoxical in nature.
It also brings into fore as to what would be the chargeable fee for those percentage of seats for which no guidelines would be framed by the commission. This operationally will mean that the present 15% which is available to private institutions including deemed universities for charging higher fee, would stand augmented to the entire remainder which could be anything between 60% or more which is a real travesty of its type.
The issue around the fees is a tricky one. Assuming that an investment of Rs 400 crores is required to set up a medical college and with a view to attract investment, the Bill permits 60% of seats to be open for managements with unfettered freedom to charge any quantum of fees in order to recoup the investment. This logic is highly debatable. It is apprehended that this will increase profiteering , corruption and reserve medical education only for the rich and well off.
10. Licentiate examination :-
As per section (15) of the Bill, provision is made for introduction of licenciate examination mandatory after acquiring MBBS qualification. Without qualifying licenciate examination no person will be enrolled in the National register and would be entitled to practise and do further post graduate courses. Further the standard and level of licenciate examination would be such that the students belonging to backward communities would find it great difficulty to clear the same easily and handily. This would cause a great harm to them because they would neither be able to practice nor would be able to take admission to PG courses. In addition even the students learning in medical colleges situated in remote areas as well as backward areas/states they will also suffer in a similar manner. This handicap would be equally applicable to the students passing out from north-east region as well. The net result would be that thousands of students passing their MBBS examination belonging to backward communities learning from backward areas including north-east region would not be able to practice timely and also seek admission to PG courses for want of clearance of the licentiate examination because of its higher standards.
As per proviso 2, section 33(1)(d) of the Bill, it stipulates that ‘the commission may permit a medical professional to perform surgery or practice medicine without qualifying the National Licenciate Examination, in such circumstances and for such period as may be specified by regulations’. This operationally means that without ascertaining of the required levels and certification thereto the commission would be permitting people to practice surgery and medicine in an open ended manner is nothing less than legalizing quackery in an operational sense and playing with lives of the people at large. Such sweeping powers are not only illegal but will give ample scope of manipulation and corruption.
Making exit exam as the licentiating exam for practice of medicine will have another harmful effect which is currently seen in NEET and NEET PG. Focus is only on clearing the exam and coaching centers to teach students how to crack the exams flourish in this scenario. Dummy schools and fake internships are resorted to by students to attend these coaching institutes. Effectively medical colleges will become dummy colleges where students may be on rolls but do not attend clinics or classes and focus only on the coaching institutes to clear the exit exam. This will result in doctors who are good in multiple choice questions but have no clinical skills or acumen.
Also if licentiating exam is to be introduced it has to be introduced across the board including those who take bridge course to practice modern scientific medicine.
This licentiating exam is going to produce an army of doctors who are MBBS qualified, done internship have a degree in modern scientific medicine but who cannot practice medicine. Some thought needs to be given to utilization of this army of doctors maybe even in rural areas or as residents to work under supervision in hospitals but not to practice independently.
11. Cross Pathy and Promoting the Quackery
In view of the shortage of qualified doctors, the urgency to address the primary health needs of the communities and public health that are now largely being provided by unqualified quacks, the government has, since 2010, been requesting the MCI to institute new cadres of public health personnel along the lines of the LMP’s (Licentiate in Medical Practice) during the British days that worked very well.
Instead of mandating the board related to undergraduate education and the NMC to consider such options, keeping in view the current realities prevailing in the country, the Act has introduced a system under which the Commission and the heads of the councils of Ayush can, by a simple voice vote of those present, design bridge courses legalizing Ayush practitioners to prescribe allopathy medicines. At all levels – primary level to post graduate such crosspathy seriously endangers the credibility of all the systems of medicine and thus should be seriously negated/opposed.
The propaganda that there is a dearth of MBBS doctors has been promoted to cover up for Government failures. There are only 30000 odd Primary Health Centres in the country and at one time only about 3000 vacancies for MBBS doctors to work as Medical officers in them. At last count we have more than 60000 MBBS doctors being produced in the country besides those who do their degree from foreign countries and pass the exam to practice in India currently. This leads to gross unemployment and underemployment of MBBS doctors in the country. The deficiency is in specialist posts and making the AYUSH do a bridge course is not going to fulfill that deficiency.
We need to know exactly how many MBBS doctors if produced yearly will fulfill our needs. As per WHO standards we should have 1 doctor for every 1000 population (It does not say 1 MBBS doctor). AYUSH qualified doctors are 7.5 lacs, MBBS doctors are about 9.5 lacs in the country. Which makes 1 qualified doctor for every 735 population in the country. Even if we assme that the Government does not regard the qualified AYUSH as doctors fit enough to treat Indians using their systems of medicine still with 60000 MBBS doctors being produced yearly it will take only 5 years to reach the magic figure when ratio of MBBS doctors to population will be 1;1000. If these figures are true where is the need for bridge course to train AYUSH to practice modern medicine. If for political reasons Government still considers it prudent then the bridge course doctors should also be made to give the licentiate exam.
Besides this the idea of bridge course will promote AYUSH colleges by students who do not qualify to get admission in MBBS through NEET doing an AYUSH degree and later through a bridge course backdoor enter the mainstream modern medical practice. This degrades our heritage of Ayurveda, Unani and others. To promote these systems of medicine it is essential to maintain them in pure form without dilution and contamination. Modern scientific research in Ayurveda should not be confused with crosspathy.
12. Separate National Register :
As per section 55(2)(zl) of the Bill, the EMR Board shall maintain a separate National Register including the names of licensed Ayush Practitioners who qualifies the bridge course devised by commission. By an explanation, Ayush Practitioner has been defined as a person who is a practitioner of Homeopathy or a practitioner of Indian Medicine of the Indian Medicine Central Council Act, 1970.
This act contemplates bridge courses even for the practitioners of homeopathy to enable them to prescribe such modern medicines at such level as may be prescribed. It is worthwhile to note that the names of the BAMS and BHMS graduates are already registered with their respective councils. On availing the bridge course they would be incorporated in a separate register maintain by medical commission, which would mean that they would be having duel registrations with two registering councils, which is neither open nor permissible. Further, the disciplinary jurisdiction on such persons with reference to breach of ethics is not indicated in the proposed bill as they have duel registrations to their credit. In a way a classical privileged group would stand created by virtue of the proposed Bill.
As such these are the flood gates that have been opened up in terms of the statutory provisions for backdoor entry into medical profession entitling practicing modern medicine.
13. Impact on employees of the Medical Council of India
As per section 58(3) and provisio thereto of the Bill, under the caption repeal and saving at its sub-section 3 clearly brings out that ‘on the dissolution of the medical council of India the person appointed as Chairman of the Medical Council of India and every other person appointed as the member and any officer and other employees of the that council and holding office as such immediately before such dissolution shall vacate their respective offices and such chairman and other members shall be entitled to claim compensation not exceeding three months pay and allowances for the premature termination of term of their office or of any contract of service.
This clause impacts the employees of the council in a very substantial manner in regard to their full time salaried status and permanence of employment in character. It impacts their future in a big manner by rendering their permanent employment to a nullity in a sudden manner and renders them to a struggle for their lives and living as a whole. As such, it has human angle specially in the context of Article 21 read with article 12 of the Constitution of India, in as much as article 12 vests entitlement to decent life and living as a fundamental right to every citizen and article 12 mandates a state (in the instant case Medical Council of India) to be an ideal employer.
14. NO NEED TO SCRAP THE INDIAN MEDICAL COUNCIL BUT CAN BE AMENDED:-
Why should Medical Council of India be scrapped in the first place? It is well known that the Medical Council of India has been used and misused time and again by politicians across party lines to start medical colleges of their own in the past 2-3 decades. To increase seats or recognize courses they have alternately arm twisted and bribed the MCI officials, which has surfaced through various forms to the world. It is well known that nearly 80 MPs across party lines either own or have interests in Private Medical Colleges. Now to blame the mess created by the same very politicians on the Medical Council of India and use that as an alibi to scrap the MCI is unjust and will certainly do more harm than good. What needs to be done is to bring amendments in Indian Medical Council Act to improve its functioning and bring transparency. Bringing NMC will bring control of medical education directly into the hands of the same politicians who own the private medical colleges which would be true conflict of interest and spell doom for the entire healthcare system.
The above mentioned objections to the various provisions of the NMC Bill clearly depict the fact that the roots of the Healthcare system in India is under serious threat and the above said Objections need to be addressed by the Central Government as expeditiously as possible so as to provide a safe and cordial environment to the Doctors who have chosen the said profession to serve the common citizens of the country. The NMC Bill will make the doctors puppets at the hands of the people who are as good as illiterate about the medical profession functioning and the motto. The Government through this bill is arm twisting the doctors into a corner for vested interest of the Private medical College Mafia. There is no way medical profession can be rid of commercialization or corruption if medical education is not made corruption free and the NMC Bill is harbinger of manifold increase in corruption and commercialization of medical education. The Government has not invested in medical education by either increasing the number of Government medical colleges or by increasing seats in them. In fact the ESI medical colleges started with much fanfare are closed or facing closure. It is better to bring improvements into the current system (MCI) rather than rejecting it outright in favor of a more faulty system (NMC).
Dr Neeraj Nagpal
Medicos Legal Action Group Trust
1184, Sector 21 B Chandigarh 160022