I don’t know how many in the medical profession are aware that the Government of India is proposing a radical overhaul of the monitoring and development of healthcare in the country and a “Draft National Medical Commission Bill 2016” is out there for consultation. It is important all stakeholders and especially those in the medical profession engage with the consultation exercise so that a meaningful progress can be made. Just as a way of continuing the debate, please see my thoughts here.
1. Both the National Medical Commission and the Medical Advisory Council seem to be very good ideas but will need real experts in the field on the panel to be effective. Governments (national and state) seem to be making most of the representation to these in the draft bill and the search cum selection committee also appears to be largely government controlled. My slight anxiety hence is that it will never be independent of influences of the government of the day.
2. The Medical Advisory Council is only advisory so I don’t think we need to take its makeup too seriously but it does not seem fair that states with significant differences in terms of size have similar representation; nor is there any provision for representation from non-public sector healthcare practitioners/players, public or other institutions here. Since this council is advisory only anyway, it should seek to obtain broader representation from the society that reflects the full spectrum of stakeholders in the delivery of healthcare as well as the public. It should be considerably expanded.
3. For the National Medical Commission I think the number of part-time members to be appointed from within the wider society as per the section 6 (6) should be increased to 14 (7 from medical profession and 7 non-doctors) from proposed 5 and there should be no need to appoint anybody from the Medical Advisory Council as suggested in section 6 (7) as these people already have their voice in the Council.
4. The search cum selection committee should be completely free of the government influence and I completely disagree with its proposed makeup. It should comprise of 10 people (5 from the profession and 5 from the wider society). The current provision outlined in section 10 (1) of the draft bill is wholly inappropriate.
5. Both the NEET (National Eligibility cum Entrance Test) and the National Licentiate Examination are great ideas if adequately implemented and will bring some necessary parity and rigour into the process of selection and medical education in the country. It should be possible to develop a system where individuals apply to institutions with these scores. But we also have to recognise that institutions (public and private) need to be able to have some say in setting up transparent qualifying criteria for admissions onto their campuses. This will be in the interest of true meritocracy and will generate a genuine competition amongst them to attract the best students. We further have to understand that merit may have multiple dimensions. At the same time, we do not need multiple examinations assessing the academic merit of students and in that sense, one examination with a clear cut-off criterion shall prove useful.
6. We do not see any details regarding the constitution of the Under Graduate Medical Education Board (UGMEB) and the Post Graduate Medical Education Board (PGMEB). If they are constituted under the auspices of a truly representative and responsive National Medical Council, one could have no real concerns with it. But we have not seen any details in the bill.
7. Under headings 19 and 22, powers and functions of UGMEB and PGMEB respectively, I think we should strongly consider adding a 10th point – “To facilitate financial autonomy and ensure financial viability for both state and private institutions”. In my humble opinion, only well-funded institutions can attract world-class faculty, develop top class research and support facilities, and provide high-quality education.
8. PGMEB will need to have separate Specialty Committees for each specialty including one for the “General Practice”. It has to ensure that individuals that qualify as trained professionals are fit for the purpose from day one and do not need any further training. To ensure this the training institutes and faculty need to be set strict goals or risk losing their credentials. The PGMEB will also have to ensure that every medical graduate in the country has an opportunity for postgraduate training. It further has to ensure that doctors are paid at par with others in the society during their long and arduous period of postgraduate training.
9. The Medical Assessment and Rating Board (MARB) can be a powerful body if it has powers to ensure facilities are adequately resourced and are fit for purpose. It will, of course, need financial and legal resources to be truly effective.
10. Section 29 (1) National Register under a Board for Medical Registration (BMR) is a great idea if properly implemented. For example, a patient sitting in a remote town should be able to check the credentials of his/her doctor on a smart phone! Medical Regulation is, however, a big area and I think the Board will need more members from the Commission to be truly effective.
11. Under section 29 (2) (i) there is a desperate need to amend existing code of ethics and make it more practical and then administer it robustly. The bill leaves the responsibility of its implementation with the state councils. The devil will lie in those details as simply delegating the responsibility might not work and we need to know what exactly will the BMR do to address departures from this ethical code of conduct.
12. Section 46 (2) of the Draft Bill: National Medical Commission Fund will have to be adequate. Any such body as the National Medical Commission and its various bodies will need a large amount of money and resources to be truly effective. I think there has to be a mechanism where the commission can examine ways for its own financial autonomy and independence from the government going forward. It is only fair that institutions receive a large public grant when they are being set up but continued reliance and patronage of the state will only make them ill-funded and dependent which usually leads to too much interference by the state.
13. What are we doing for the second objective of the bill (i.e. Encourage medical professionals to incorporate the latest medical research in their work and contribute to such research)? I think there is an urgent need to set up an Indian body (we could call it the Indian Clinical Guidelines Committee) to come up with India-centric clinically useful guidelines as well as establish local research priorities. There have to be further provisions when every medical practitioner has to submit at least one audit of a major clinical area of his practice every three years. The National Medical Commission has to also examine ways of instant dissemination and publication of such audits and research in Indian Journals (or rapid publishing platforms) easily searchable by a state of the art Indian bibliographic database. Without addressing the dissemination of audit and research, we will never be able to truly develop a strong culture of audit and research.
14. For the third objective of the bill (i.e., Provide for objective periodic assessment of medical institutions), I have not seen much in the bill. Both state and private medical institutions need a very strong regulator that can ensure our nursing homes and hospitals are fit for purpose. Such a body (let us say a Clinical Establishments Regulator) should have sweeping powers to even close down public or private institutions or take over managerial control (for public sector institutions) if need be. Such a regulator would also need to ensure that capacity is uniformly distributed in the country. The current state of overcrowding in big cities and scarcity in rural areas is a big underlying reason behind a number of unethical practices and this needs to be addressed urgently.
Above is a brief summary of my thoughts. This is obviously not the place for minutiae. This bill is a great opportunity for us to make a real change to the healthcare in India but in the name of the National Medical Commission we want to create a body that can ask the government to actually do things, not one that is run by the government. We need an institution that can persuade the government to increase its health budget; upgrade primary and tertiary care facilities; make the medical profession transparent and accountable; and above all create a culture of financial and decision-making autonomy for both itself and the various bodies under it. We need a body that has powers to close down even state hospitals if they are not fit for purpose. We need a body that can prosecute both state and private doctors for incompetence and corruption. We need a body that gives autonomy to institutions in maintaining their affairs and finances. We need a body that can summon and prosecute management of both public and private hospitals for any wrongful death. We need a strong body looking after interests of only one group of people – the patients. All this will not be possible if we replace MCI by an even more bureaucratic and government-controlled institution. Let us use this opportunity, not waste it.
Following his graduation from Calcutta Medical College and post graduation from Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Dr Kamal Mahawar is now a Consultant General and Bariatric Surgeon with Sunderland Royal Hospital in the United Kingdom. He is also an Associate Clinical Lecturer with Newcastle University and editor of renowned scientific journals. His recent book ‘The Ethical Doctor’ published by Harper Collins India examines some of the serious issues affecting Indian healthcare.