It is a fact that despite India’s economy today being one of the world’s fastest growing and third largest in terms of Gross National Health Income, the country has not been able to leverage its economic growth to achieve the desired health outcomes. It is evident from the fact that 700 million people have no access to specialist care and 63 million persons are faced with poverty every year due to healthcare costs alone. Who are responsible for such pathetic state of affairs concerning health and medical education system of the country? One would say, the governments, legislators, medical professionals and mainly the existing regulatory framework of medical education and practice in the country failed us.
The 92nd report of the Department-related Parliamentary Standing Committee on Health and Family Welfare on the functioning of MCI was presented to Parliament in March this year. The Committee has made strong observations and recommendations after examining critical issues of the sector.
Need for Radical Change
The Committee observes that the need for major institutional changes in the regulatory oversight of the medical profession is so urgent that it cannot be deferred any longer. The Committee is, however, aware that any attempt at overhauling the regulatory framework will face huge challenges from the deeply entrenched vested interests who will try to stall and derail the entire exercise. “But if the medical education system has to be saved from total collapse, the Government can no longer look the other way and has to exercise its constitutional authority and take decisive and exemplary action to restructure and revamp India’s regulatory system of medical education and practice,” the report says.
The Committee, thus, exhorts the Ministry of Health and Family Welfare to implement the recommendations made by it in this report immediately and bring a new comprehensive Bill in Parliament for this purpose at the earliest. Even though the Parliamentary Panel severely criticised the functioning way of MCI, the NDA government is in a fix when it comes to plug the holes. Senior health ministry officials say they have no powers to introduce reforms in MCI as it is an elected and autonomous body, being governed by the Indian Medical Council Act 1956. The Committee, however, says that the MCI is funded by the Government and therefore the Government must have the leverage to enforce accountability in the MCI.
In the absence of adequate medical education regulations, the rural health services couldn’t meet the need of the people. For Doctors -Patients ratio, the country is 1:1674 against the WHO norm of 1:1000. The total universe of doctors in India is much smaller than the official figure because the Indian Medical Register is not a live database and contains names of doctors who may have passed away as well as those with permanent address outside India. The Panel also notes that the medical colleges in the country are distributed in a skewed manner, with nearly 65 per cent of medical colleges concentrated in the Southern and Western States of the country which has resulted in great variation in doctor-population ratio across the states. Even if compulsory rural service is introduced throughout India, graduates of each state would be required to serve only in their state and the states with very few medical colleges would continue to be disadvantaged. The Committee has recommended to put in place an institutional mechanism to ensure better distribution of medical colleges across the country.
The quality of medical education in the country is at its lowest ebb; the current model of medical education is not producing the right type of health professionals that meet the basic health needs of the country because medical education and curricula are not integrated with the needs of our health system; medical graduates lack competence in performing basic healthcare tasks like conducting normal deliveries; instances of unethical practice continue to grow. But the MCI, a predominantly elected body, has not been able to spearhead any serious reforms in medical education to address these gaps.
Safeguarding the Quality
The paramount consideration for the regulation of medical education should be to ensure that it safeguards the quality of medical education and well serves the needs of India’s health system. This is far more important than protecting the elected character of the regulatory framework. Electoral processes, by their very nature, bring about a lot of compromises and tend to attract professionals who may not be best-fitted for the heavy academic responsibilities of a regulatory body and it is, therefore, possible that professionals of the highest standards of eminence and integrity would be thrown up through electoral processes.
The Committee is also of the opinion that the governance of medical education in India must be accountable to the people of India. Ultimately, popularly elected governments are answerable to the people for the performance of the health system, not the MCI.
Establishment & Management of Medical Colleges
The Panel is of the considered view that the existing Minimum Standard Requirements (MSRs) for establishment of a medical college are irrational and artificially rigid standards which are proving to be great impediments in the establishment and expansion of medical colleges. The medical graduates emerging out of the medical colleges in the country lack confidence and skills in performing basic healthcare tasks and even basic skills like conducting a normal delivery and providing early care for a fracture are not within the competency of a graduate doctor.t
One of the critical gaps in the system is the separation between the medical education system and the health system. The primary reason behind this separation is that our medical graduates work and train in tertiary care institutions which often deal with exotic and rare diseases. Since the vast majority of patients seek healthcare services in small clinics and out-patient departments of small hospitals, the graduate doctors are not exposed to primary and secondary healthcare conditions. The MCI has failed to address this separation between the medical education system and the health system in the country. This gap needs to be fulfilled for the rural sector. At specialty level also there is going to be huge gap as India is a country of 1.24 billion that will reach 1.7 billion by the middle of the century. Therefore, only 24,000+ PG seats are unquestionably much less than national needs.
Professional Conduct of Doctors
The Committee observes that the oversight of professional conduct is the most important function of the MCI. However, the MCI has been completely passive on the ethics dimension which is evident from the fact that between 1963 and 2009, just 109 doctors have been blacklisted by the Ethics Committee of the MCI. Considering all these factors, the Committee has recommended that the Code of Medical Ethics needs to be well-defined to take care of the concerns of public safety and malpractices or medical negligence by doctors so that the doctor-patient relationship which has taken a severe beating, can be repaired and retrieved.
The Committee was astonished to note that the MCI has notified on February 1, 2016, an amendment to clause 6.8 of the MCI Code of Ethics Regulations, deleting the words “and professional association of doctors" and exempting professional association of doctors from the ambit of MCI Code of Ethics Regulations, 2002. The Committee observes that exempting professional association of doctors from the ambit of Ethics Regulations is nothing short of legitimising doctors’ associations indulging in unethical and corrupt practices by way of receiving gifts in cash or kind under any pretext from the pharma industry or allied health industry.
Public health activists were very critical of this move of the MCI and they pointed out that “an action that is ethically impermissible for an individual doctor cannot become permissible if a group of doctors carries out the same action in the name of an association.”
The Committee also could not uncover any rational reason as to why the MCI has taken such a retrograde decision. It seems that the MCI has become captive to private commercial interests, rather than its integrity in public interest.
The Committee also finds it intriguing that instead of intervening to thwart attempt of MCI at subverting the system, the Ministry has meekly surrendered to MCI. The Committee recommends that the Ministry should take immediate action in the matter to ensure that the illegality committed in terms of violation of ethical standards of 2002 Regulations, either by an individual doctor or a group of doctors in the form of an association is not kept out of the jurisdiction of MCI and the words “and professional association of doctors” are restored to clause 6.8 of the MCI Code of Ethics Regulations 2002 so that no immunity, whatsoever, is accorded to any association or society of doctors.
Corruption in MCI
The Committee was shocked to find that compromised individuals have been able to make it to the MCI, but the Ministry is not empowered to remove or sanction a Member of the Council even if he has been proved corrupt. Such state of affairs are also symptomatic of the rot within and point to a deep systemic malice.
The Committee is all for professional autonomy, but autonomy sans accountability tends to degenerate into autocracy and therefore cannot be acceptable. The Committee recommends that the Ministry should take expeditious action to amend the statute or enact a new legislation in a manner that it comprises within its ambit accountability provisions as well and empowers the Government with legal authority to intervene in matters of corruption.
Game changer reforms of transformational nature are therefore the need of the hour and they need to be carried out urgently and immediately. Because, if revamping of the regulatory structure is delayed any further on any grounds including political expediency, it will be too late as too much momentum will have been built to offset attempts at reversing the direction later, with the result that our medical education system will fall into a bottomless pit and the country will have to suffer great social, political and financial costs.
Finally, the Central government needs to take lead and urgent steps for much-awaited reforms. The MCI can no longer be entrusted with that responsibility in view of its massive failures. The Government must therefore fulfill its commitment to preserve, protect and promote the health of all Indians by leading the way for a radical reform which cleanses the present ills and elevates medical education to contemporary global pedagogy and practices while retaining focus on national relevance.