Medical Education Reforms: Examining the National Medical Bill's Questionable Provisions

India needs a medical education system that produces competent healthcare professionals.

At present, a government doctor in India attends to 11,802 patients, against the World Health Organisation (WHO)-recommended ratio of 1:1000. The National Medical Bill, 2019, passed during the recent budget session of the Parliament, seeks to address this imbalance by improving access to quality and affordable medical education. To do this, the bill proposes replacing the Medical Council of India, which regulates medical education, with a centrally-controlled National Medical Commission (NMC).

To regulate admissions into educational institutions, the bill sets up a National Eligibility-cum-Entrance Test (NEET) for admissions for “super-speciality” medical education, as well as a National Exit Test (NEXT) for eligibility to pursue postgraduate studies, and to obtain licences to practise medicine. Further, a fee cap will be in place for only 50% of seats in private colleges, a departure from the pre-existing norm to regulate fees for 85% of seats in private institutions. Deemed private universities in Maharashtra charge around Rs 70 lakh for a 5 year MBBS course, and a private medical college in Lucknow was reported to have charged Rs 1.2 crore for a five year MBBS. Experts contend that removing a fee cap would take away from the government’s promise to provide affordable universal healthcare, and instead concentrate specialist doctors in metropolitan areas. The Indian Medical Association (IMA), a voluntary organisation of doctors, has also criticised the bill. They argue that it will encourage further privatisation of  medical education, and the constitution of the NMC would take away autonomy from state medical councils.

This reading list looks at the issues highlighted by the National Medical Bill, and at previous attempts to revamp medical education in India.

1) Producing Competent Doctors
By computerising entrance exams, students are tested on irrelevant trivia, rather than on their ability to grasp concepts and principles. K S Jacob writes that medical education in the country suffers from a host of issues: poor pedagogy, low student–teacher ratios, incompetent faculty and the absence of faculty appraisals. Jacob argues that students are qualified to be doctors but do not know how to practise medicine.

Undergraduate medical education seems to prepare doctors only to write postgraduate entrance exami-nations for specialisation, completely undermining the goal of basic healthcare delivery through family medicine, gen-eral practice and primary care. Systemic problems of higher education in India, particularly the attitude of universities in limiting their role to conducting exams and awarding degrees, compound the situation. Crass commercialisation of medical education, with mushrooming of for-profit institutions, adds to the complexity of the issues involved.

While efforts have been made to restructure education, they have failed. Jacob writes that it is necessary to address the politics of medical education to achieve substantive change. Political will to improve public access to healthcare, he says, is missing.

The rise of private medical educational institutions and the flourishing system of specialist healthcare has meant that ensuring a supply of basic doctors who can independently practise in primary care is not a priority. The private sector not only prefers specialists working out of tertiary care centres, but also does not seem to want basic doctors capable of independent primary care, family and general practice. Corruption in the regulatory body coupled with similar trends in Indian politics and society mean that quality medical education is always on the back burner. Even those who talk about it and those who run pilot projects know that scaling up innovative efforts to the national level is next to impossible in the current socio-political and economic context.

2) Examining the Draft NMC, 2017
The Medical Commission of India, which was dissolved in 2010, constituted of representatives of different states, union territories, universities as well as of members nominated by the central government. The draft National Medical Commission (NMC) Bill, 2017, does away with this structure. The bill makes provisions for a central National Medical Commission, to be appointed entirely by the government, and all power will be vested in the chairperson of the body. Pradip Mazumdar writes that this structure could dent any scope for states’ autonomy.

By splitting the selection, advisory, and accreditation process into three separate boards, the bill aims to create a system of checks and bal-ances. However, all the members of the accreditation board are considered to be ex-offi cio members of the advisory board. This means that instead of having different boards that can monitor and regulate each other, the NMC would have a singular body with two different heads, the possible corruption potential of which con-travenes any arguments about good gov-ernance. Moreover, a shift from the elected MCI to the nominated NMC—a shift perhaps from a democratic system towards an autocracy—does not bode well, either.

Further, Mazumdar writes that the draft NMC would see the increasing commercialisation of education. Setting up a medical college costs around Rs 400 crore. To recover such investment, the NMC bill proposes that medical colleges charge any amount of fees for 60% of students.

The government appears to have greenlighted corporate greed-driven overcharging of capitation fees, while simultaneously supporting the monopolising of medical education by the rich. In addition, corrupt practices are likely to increase. Since medical education is directly linked to public welfare, corruption in healthcare regulatory bodies has direct consequences for the quality and cost of healthcare services. Therefore, the government should introduce strict regulations and innovative enforcement mechanisms to regulate the profiteering of private medical colleges and ensure universal access to medical education.

3) Education as Exclusion
The draft NMC Bill, 2017, also proposed a uniform National Eligibility cum Entrance Test (NEET) for admission. However, Pradeep Kumar Choudhury argues that standardising a test for aspirants who come from different social and economic backgrounds has its own set of difficulties. Different state boards have their own syllabus, and those students who study in vernacular languages will be at a significant disadvantage.

Tamil Nadu has not had entrance examinations since 2007 and students wanting to pursue medical courses are admitted on the basis of their Class 12 final examination scores. This is done with the aim achieving parity between rural and urban students. As many southern states expressed concern over the languages of the entrance examination, effort should be made to conduct NEET in the language of the students’ choice. Perhaps the government is making an attempt towards resolving this issue. Third, there are wide variations in the quality of education provided in metropolitan and rural areas. The strong urban bias that undergirds NEET would utterly wipe away the prospects of students in small towns and villages who have no access to good schools and coaching centres. This is a serious concern but the solution is to improve the quality of schooling in rural areas.

Further, Pradip Mazumder argues that NEET will not ensure that students gain admission solely on merit. NEET will only favour urban, rich, upper caste aspirants who can avail of private tuition classes.

Medical  entrance  coaching  is  already a booming business, and accusations  of  there  being  a  corrupt  nexus  of  coaching  centres  and  medical  colleges  has  raised  questions  about  conflicts  of interest.  Enforcing  NEET  will  certainly  result in the mushrooming of such corrupt and   highly   priced   coaching   centres   beyond  the  reach  of  most  talented  stu-dents. Thus, under the pretense of merit, medical education will be made selectively available to privileged social elites.

4) Ensuring a Minimum Standard of Healthcare
While the proposal for a NEXT exit examination is desirable for graduating MBBS students to ensure a minimum quality of medical professionals, Sambit Dash and Anant Bhan argue that it could be “just another examination” and fail to ensure that a doctor possesses basic skills. The authors argue that as a bare minimum, doctors need to be able to exhibit empathetic care, be knowledgeable enough to examine patients properly, and be able to perform a mandated set of clinical procedures. To do this, Dash and Bhan advocate an exit examination that tests both theory and clinical competence.

The written examination would test the cognitive domain, or the knowledge and understanding of a student, while the clinical component would test for psychomotor skills and competence. In addition, the examination should be designed to test the affective domain as well. This is in line with the objectives of the MBBS curriculum An MCQ-only NEXT will not serve this required purpose. If it is to be structured as another MCQ-based examination, and given the high stakes of acquiring a prized postgraduate seat associated with it, it could lead merely to a further padding of the financial kitty of already mushroomed postgraduate entrance coaching centres in the country, which probably would start advertising and running classes for clearing the NEXT.

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