An attempt to improve medical education and stimulate research
The bill to replace the Medical Council of India (MCI) with a National Medical Commission (NMC) has been referred to the parliamentary standing committee on health, for review within a month. Fierce debates on the intent and content of the bill continue to rage, as critics decry it as an assault on the medical profession, enthusiasts hail it as a long awaited redemption of medical education and supporters of reform seek revisions to remove infirmities in the bill.
As health systems world over move from physician-centric to patient-centric models of health care, medical education has to become responsive to the needs of the people, while adopting innovations in pedagogy and practice and stimulating path breaking research. While we also need to correct the shortages of nurses, allied health professionals and community health workers, the NMC provides an opportunity to commence reform of health education to provide health care with greater outreach, effectiveness, equity and empathy.
The MCI was embroiled in controversy for several years before the Supreme Court intervened to dismantle an entrenched power structure. Attempts to recast medical education, by proposing a National Commission for Human Resources in Health (NCHRH) or amending the MCI Act, failed during the past decade. The NMC bill is a fresh attempt to remove the regulatory cobwebs that cling to medical education and repurpose it for strengthening the health system and stimulating productive research.
The bill envisages a 25-member commission, with mostly nominated members, operating through four subsidiary boards regulating undergraduate education, postgraduate education, medical assessment and rating, and ethics and medical registration. A Medical Advisory Council (MAC) guides the NMC and provides representation to states and union territories.
A common National Entrance-cum-Eligibility Test (NEET) will determine entry to undergraduate courses, while a National Licentiate Examination (NLE) at exit will both provide the permit to practice and determine selection to post-graduate courses. While the NLE enables standardisation, NEET will face the challenge of providing a level playing field to students schooled in diverse languages and varied curricula across the country. The parallel track of post-graduate education, governed by the National Board of Examinations (NBE), has been preserved with autonomy and equivalence.
The largely nominated nature of NMC membership has drawn criticism from the IMA, which espouses the ideal of self-regulation by elected representatives of the profession. However, the harsh reality of skewed elections and tarnished governance in the MCI has exposed the frailty of self governance. In contrast, the nominated boards of the All India Institute of Medical Sciences (AIIMS) and the NBE have performed well. However, the federal structure of India must be better reflected in NMC membership.
Most controversy around NAC concerns the proposal to provide cross learning pathways between Allopathy, Ayurveda and Homeopathy. While cross learning is useful to promote complementarity, the IMA denounces ‘bridge courses’ that draw non-allopathic graduates to allopathic practice, without the requirement of the NLE. Instead of undermining traditional medicine and treating non-allopathic healers as easily available substitutes , they should be adequately supported to practice what they were trained for. What is missing in the NMC is an inter-professional education platform, which connects medical, nursing and allied health professionals’ education. Our health system needs nurse practitioners, nurse anaesthetists , physician assistants, community health assistants, dialysis technicians and the like. Primary health services in particular should become less doctordependent.
The NMC overreaches in some assigned functions. Medical research is to be ‘regulated’, ignoring the role of the department of health research, the Indian Council of Medical Research, other science agencies and institutes, and universities in basic, translational, public health and clinical research. Strangely, the NMC has been asked to prepare a roadmap for healthcare ‘infrastructure’ in the country, usurping the role of state and central health ministries.
There is clear government intent to encourage private investment in new medical colleges and increase production of medical graduates and specialists. While the objective is laudable, it is doubtful if these incentives will encourage private investment in the states that have very few medical colleges. The government has to accept responsibility for investing in new medical colleges, linked to upgraded district hospitals in these states.