The end of the Medical Council of India

Proposed changes

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.

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.