The end of the Medical Council of IndiaBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5070 (Published 04 December 2018) Cite this as: BMJ 2018;363:k5070
- 1George Institute for Global Health, New Delhi, India
- 2University of Oxford, UK
- 3University of New South Wales, Sydney, Australia
- Correspondence to: Vivekanand Jha
India’s government delivered the final blow to the long suffering Medical Council of India (MCI) on 26 September 2018 with the promulgation of a presidential ordinance recommending its dissolution in order to move ahead with its replacement by a National Medical Commission (NMC).1
Successive governments have formed committee after committee to reform the MCI, but their recommendations were not implemented (see box). The tipping point for this government seems to have been reached when the latest reform committee resigned in early September. The reasons given were the MCI’s lack of cooperation with its directions, its refusal to share information in relation to the controversies in the process of assessing medical colleges, and its tardiness in managing admission processes—which led to a large number of postgraduate seats remaining unfilled. Other criticisms included its failure to act against medical professionals charged with unethical practices, and failure to reform medical education.2 The suddenness of this step is underscored by the fact that the government had directed the MCI to hold fresh elections less than before the dissolution,and a few states had even started the process.
The draft National Medical Commission Bill was introduced in the lower house of the Lok Sabha (India’s parliament) in December 2017.3 Several sections of the bill received criticism, however, and were later modified by the standing parliamentary committee on health.4 Particularly contentious were proposals for a six month bridge course that would have permitted practitioners from the indigenous AYUSH (ayurveda, yoga, unani, siddha, and homoeopathy) systems to practise modern medicine, purportedly to tackle the shortage of doctors; the proposal of a national licentiate examination for undergraduates; and the intent to give private medical institutions the freedom to set their own fees for 60% (later reduced to 50%) of their places, pricing them out of the range of most Indians.
In the proposed bill, the governance of the NMC is vested in a body of 25 members, 21 of whom will be doctors, nominated by the union or state governments or approved representatives from various ministries and institutions. For the first time, a three member patient representation has been proposed. Four independent boards are to be constituted to oversee undergraduate and postgraduate courses, assess and accredit medical institutes, and register medical practitioners.
The proposed structure has met with criticism,5 the biggest being the lack of clarity on how simply replacing the elected council with a nominated one will bring reform. There is apprehension that people close to the government of the day—rather than truly independent and efficient reformers and administrators—will be nominated, and that the private sector will continue to exercise a disproportionate influence while the healthcare needs of the general public are neglected. This reflects India’s healthcare system, in which the private sector provides more than 80% of services, and most of the new medical colleges are in the private sector (often under the patronage of influential backers, including politicians) and are engaged primarily in profit making.6
Questions over transparency
It is also unclear how the commission will ensure objectivity, transparency, and freedom from discrimination, as well as uphold the key principles of good regulation—proportionality, accountability, consistency, transparency, and proper targeting.7 The process of tackling misconduct has been left to state medical councils, with the commission having an appellate jurisdiction. Mysteriously, the central government—rather than any judicial body—has been designated as final arbiter.8
All this, however, must await the passage of the bill through parliament. In the interim, a caretaker board of seven governors has been appointed.1 All of these people have impeccable reputations, but they already hold demanding day jobs and it is not clear how they will find the time to manage the board.
The board recently announced the introduction of a competency based undergraduate curriculum,9 with clinical immersion from the first year, time for self learning, the ability for students to choose elective subjects, and a new course entitled Attitude, Ethics, and Communication. A similar announcement, however, was made in 2017 by the then president of the MCI,10 and the difference between the two is unclear. Also unclear is who will teach these courses, since existing medical college faculties have no training in these subjects.
A timeline of reforms proposed for the Medical Council of India
1934 MCI established under the Indian Medical Council Act, 1933
1958 Act repealed, MCI reconstituted under the Indian Medical Council Act, 1956
1993 Act amended to allow MCI to regulate permission to establish medical colleges, decide admission capacity, and study curriculums
2001 Act amended to govern registration of recipients of medical degrees from foreign institutions
2005 Amendment to act proposed to reduce the proportion of elected members and increase accountability to government, rejected by the standing parliamentary committee on health (SPC) on the grounds that it undermines the MCI’s autonomy and democratic nature
2010 The MCI’s president arrested on charges of bribery
• Government appoints a board of governors to supersede the MCI for one year, term later extended until 2013
2011 The National Commission for Human Resources for Health Bill introduced to reform regulation of medical education, rejected by the SPC on the grounds that it undermines the MCI’s autonomy and democratic set-up
2013 Amendment to MCI act proposed to reduce the term and prescribe conditions for removal of office bearers and increase accountability to government, rejected by the SPC on the grounds that it gave the government sweeping powers
• MCI reconstituted after fresh elections
2016 Supreme Court appoints a three member oversight committee headed by a former Chief Justice of India
2017 National Medical Commission Bill introduced; the SPC recommends modifications in March and August 2018, currently pending approval
• Government proposes a new oversight committee headed by a member of the National Institution for Transforming India
2018 Presidential ordinance dissolves MCI, appoints board of governors
The commission will also need to deal with matters not covered by this bill. There are two parallel streams of postgraduate medical education in India: one is controlled by the MCI and the other (in private hospitals) is controlled by the National Board of Examination. The equivalence of degrees awarded by the two types of universities for entering the pool of medical academia has been a matter of dispute.11 Another matter of debate is the extension of prescription rights to the non-physician medical workforce, such as nurses, pharmacists, physician assistants, and optometrists, among others.12
Finally, in an era when the focus is increasingly on making healthcare systems patient centred, the doctor and hospital centred approach that the new bill takes is disappointing. The lack of debate among stakeholders raises the danger that the proposed changes will end up being cosmetic, rather than structural. It remains to be seen whether this is just a slash and burn exercise or will indeed accomplish the more arduous task of institution building.