HEALTH related issues are in the public eye far too often. Except for the occasional feel-good personal story, they are mostly sensational and of the wrong kind. India continues to rank poorly in various crucial health related indicators, be it maternal mortality, infant mortality or anaemia in women.¹ Inadequate access to primary healthcare for large sections of the population, high costs of private health care and an overall increase in non-communicable diseases such as diabetes, hypertension and cancer, together keep ‘health’ in public focus. The discussions most often revolve around a ‘shortage of doctors’, a lack of ethics in medical practice and the perception that the profession is ‘sold’ to the pharmaceutical and medical devices industries.

Policy interventions taken in the first decade of the century, towards meeting various health targets set by the Millennium Development Goals (MDGs), had a significant impact on the health indicators. Recent interventions, aimed towards meeting the SDG goal number III of ‘health and well-being’, adopt a more holistic approach that addresses well-being rather than disease. Healthcare delivery has always been doctor centric and doctors are trained to various levels of competencies to treat disease. The new paradigm for health shifts the burden from the ‘doctor as a healer’ to a team of healthcare professionals that include, among others, nurses, pharmacists, physiotherapists, counsellors, ANMs, led by a doctor. Hence, medical education and training needs to be re-looked at from the perspective of these new paradigms.

 

In 1947, there were 23 medical schools offering an undergraduate degree of Bachelor of Medicine and Bachelor of Surgery (MBBS) recognized by the Indian Medical Degrees Act No. VII of 1916.² The IMC Act of 1933, provided for the formation and regulation of postgraduate medical education. In 1956, the IMC Act was further amended and the Medical Council of India (MCI) was vested with the power to give ‘permission for establishment of new medical college, new course of study’ and ensure ‘minimum standards of medical education’. The selection, training and examination of the candidates for the undergraduate (UG) and postgraduate (PG) education was decentralized and the responsibility of the university awarding the degree while the MCI provided general oversight within its prescribed powers.

From the 1990s, the increasing demands for trained healthcare professionals, financial constraints, and an overall lack of commitment to publicly funded education, led to government encouraging the growth of private educational institutions. To strengthen the more centralized control of regulatory supervision, an amendment (the draconian Section 10A) to the MCI Act (1956) was passed in 1993.³ This enhanced the power of the government, with ‘(a) no person shall establish a medical college; or (b) no medical college shall (i) open a new or higher course of study or training (including a postgraduate course of study or training) which would enable a student of such course or training to qualify for the award of any recognized medical qualification; or (ii) increase its admission capacity in any course of study or training (including a postgraduate course of study or training) except with the previous permission of the central government obtained in accordance with the provisions of this section.’ This established the government as a watchdog of the regulatory body.

In 2000, there were 174 medical colleges of which 115 were government owned. Between 2001-09, 122 new colleges were added of which only 30 were in the public sector.⁴ This rapid expansion of the private sector under the provisions of Section 10A, created a ‘license-permit’ raj. The infrastructure requirements (for example, 20 acres of land for a new college with 100 students) and teacher-student ratios, had to be rigidly met, making it expensive to start a college. A large number of the 92 new private colleges were opened under the ownership or patronage of politicians of various political affiliations.

 

Although medical seats were allotted based on various types of central, state or institutional entrance tests, private colleges were allowed to retain ‘management’ seats which were auctioned for outrageous amounts. The fee for non-management seats was higher than for those in the government colleges. The rampant commercialization of the admission process led to the Supreme Court ordering the states to set up fee regulatory committees. Yet, every admission season kept throwing up new scandals.

As of today, there are 60,680 medical seats in 497 MCI recognized medical colleges across the country (MCI website), approximately half being private colleges.⁵ However, there are only about 20,000 MD/MS seats and about 7000 NBE seats for PG training. The medical register lists 10 lakh doctors, of which approximately eight lakh are practicing the profession. Since the registration of PG qualification is not mandatory, there is no clear information on how many of them have postgraduate training.

 

The Medical Council of India was a body where each state had a representative who was elected by all the registered doctors in the state, and one nominated representative. It was a position that was vied for. The council elected its own office bearers and was totally autonomous. The council aggressively increased fees for all its activities, such as approvals for new colleges, an increase of seats in the existing colleges, professional registration etc., and was financially independent of the government.

The many ills of the system of regulation and the rapid increase in private colleges from 2000 to 2009 led to a low point in medical education in the country. In 2009-10, the president of the MCI was implicated in corrupt practices and the council was set aside by a special ordinance. The council was replaced by a nominated Board of Governors which was in place from 2010 to 2014 (I was a member for the year 2010-11). Parliament, however, is never comfortable to extend an ordinance indefinitely, and efforts of the government to introduce changes through a new act were unsuccessful. The elected council was brought back with some minor modifications in 2014.

In the meanwhile, concerned with the hue and cry raised by cases of medical malpractice and the doctor-industry nexus, the Parliamentary Standing Committee on Health held hearings from all sections of the sector – doctors, the IMA, industry etc. Their report of 2015 was highly critical of the MCI and its existing system of governance and oversight of both education and the profession.⁶

 

From the ’70s onwards, India followed the global trend moving towards curative medicine, leading to the increasing demand for specialists, resulting in the rapid expansion of private medical care and corporate sector hospitals. In order to meet this demand, the National Board of Examinations (NBE), a parallel stream to university degree based training, was established in 1975. Though it did not have the status of a degree, the intention was to accredit speciality training in non-teaching hospitals and increase the available pool of specialists. Over time, the increasing political voice of a large number of NBE certified specialists and shortages in teaching faculty, led to the NBE certification being equivalent to the university awarded degrees. MCI was coerced into accepting this position.

In 2014, the government constituted a committee under the chairmanship of Professor Ranjit Roy Chaudhury, to provide suggestions for a new oversight mechanism. I was a member of this committee. We suggested a new architecture consisting of a commission with nominated, and not elected, members. It would have independent bodies to regulate UG, PG education, one to provide an oversight of education through accreditation and a fourth one to look after the medical register and ethics. It also made the novel recommendation to have a non-medical member for the ethics oversight. State representation was to be through an advisory council.⁷

Following the change in government in mid-2014, a new committee under the supervision of Niti Aayog brought out a draft bill to establish a National Medical Commission (2017) that was based, to a large extent, on the recommendations of the Ranjit Roy Chaudhury Committee Report.⁸ The draft bill provides for an enlarged membership to include non-medical nominees as well as elected medical members. This bill has been approved by the cabinet and tabled in the Parliament. In the meanwhile, in September 2018, the government once again set aside the council by an ordinance which is currently being run by a government appointed Board of Governors consisting of directors of government owned institutions and chaired by a Member of the Niti Aayog.

 

The National Health Policy document of 2017 envisages the provision of a larger package of assured comprehensive primary healthcare than what has been delivered through the Health and Wellness Centres.⁹ This includes care for major non-communicable diseases (NCDs), geriatric healthcare, mental health, palliative care and rehabilitative care services as well as free diagnostics, free drugs and free emergency and essential healthcare services in all public hospitals. There is a need for appropriately trained manpower in all spheres of healthcare, including doctors, to achieve these goals.

The present UG curriculum is centrally structured and uniform for the country, with no scope to address locally relevant health issues. In order to meet the market demand for specialists, the curriculum has moved unidirectionally towards specialization. The present curriculum leaves graduates ill-equipped for independent practice and with no option but to specialize. Training in attitude and leadership skills needed for a doctor to be a leader and member of a larger health delivery team that looks at wellness rather than disease, are not inculcated. The ethics of medical practice, health economics and other subjects essential for working in the modern world are not included. Since scarce PG seats are allocated based on a competitive all India MCQ based test (NEET), which does not test skills, medical students tend to invest time and energy on theoretical knowledge.

 

Centralized control over curriculum is an outdated concept across all fields of education. World over, the department specific model of UG medical training has been abandoned as it fails to make optimal use of the training period. The current curriculum with subjects taught in silos and emphasis on summative evaluation of retained information is neither challenging for the student, nor does it help to train a competent graduate or specialist with the required analytical skills. While there are a large number of dedicated and outstanding medical teachers, for the majority of medical graduates, a teaching career is not the first option, since independent practice and service in the corporate sector give far greater renumeration and social status.

The PG curriculum is also centrally controlled but more dynamic than the UG one, as it is more market driven and there is demand for training in the latest technologies. The demand for super-specialization has led to an even higher qualification, the DM and MCh degrees and their equivalents in the NBE.

The MCI, being a predominantly elected body, its membership comprising mostly of non-academic professionals, makes it ill-equipped to take informed decisions on curriculum, regulatory requirements etc. In fact, there are few examples in the world where medical education is regulated by a body elected by members of the profession.

 

The original mandate of the MCI was not oversight of education. However, this has become its predominant activity. The present system of granting permission to start and enhance UG and PG seats, has driven up the cost of setting up institutions and consequently also the fees. The effort is not to rate quality of teaching or competence of the graduate, or assess practical skills as against theoretical knowledge. The rigid requirements for infrastructure has provided the basis for corruption in the system.

India has one doctor per 1700 population, as against the WHO recommendation of one per 1000 of population.¹⁰ These numbers, however, do not reflect the fact that the distribution of available manpower is highly skewed. There is significant clustering of the available doctors in urban and semi-urban locations and higher representation in the more developed states of Maharashtra, Karnataka, Andhra Pradesh, Tamilnadu and Kerala. The rural and remote areas as well as less well developed states of Rajasthan, Uttar Pradesh, Madhya Pradesh, Bihar, Orissa and Bengal, while having poorer healthcare indicators and need for greater medical intervention, have fewer doctors. The MCI clearly failed in building frameworks that would incentivize establishing colleges in the supply deficit regions, leading to concentration of medical colleges and doctors in a few states that account for over two thirds of all medical colleges in the country.

The National Eligibility cum Entrance Test (NEET) has become the only route for admission to all the UG colleges. It has been promoted as the final panacea for many of the evils associated with the admission process, especially in private medical institutions. However, this is not an equitable solution as it advantages urban and English medium students, especially those who can afford the expensive coaching that has become the norm.

 

The public perception of the doctor swings between ‘God on earth’ and ‘greedy and unethical’ – both of which are unjust and unwarranted epithets. Only doctors registered with the MCI are legally allowed to practice and every graduate who successfully completes 12 months of internship can get a registration which is for life. There is no requirement to register postgraduate qualifications.

Doctors suffer because of the expectations of the public and since medicine is not a certain science, even the best intentioned therapies may not work. However, there is little discussion of ethical issues during training. Often genuine mistakes, or errors of omission rather than commission, are misunderstood due to a lack of adequate communication. Whatever the situation, the patient should feel empowered to question decisions and outcomes, calling for clarity and provisioning of pathways for complaints and redressal. However, these systems are not robust and appear opaque. The complaints are dealt with by state and central Medical Councils and committees of doctors. This generates a lack of trust and a feeling that doctors protect their own kind. It also re-enforces the public’s negative perceptions of the profession.

 

The training of a well rounded physician, with the competence and confidence to practice independently and help meet the health goals of the country, needs major and urgent restructuring. The current static, unidirectional process is not in tune with the young of today. In an era of instant knowledge access, a major rethink of the teaching-learning process is called for. Continuous, ongoing 360o assessment should become the norm.

An ongoing decentralized mechanism to discuss curricular issues and generate broad guidelines for a locally relevant curriculum should be put in place. Training should encompass all the required core competencies with emphasis on skill development. Ethics, medical humanities, leadership and other aspects essential for making the young graduate a well rounded physician, would bring the excitement back into medical learning. The linkage to the university system should be considered and encouraged in order to enable the incorporation of medical humanities, a new specialty that is rapidly being adopted by many leading medical colleges around the world.

Many of these aspects have been addressed in the new Competency Based Medical Curriculum¹¹ that has recently been released by the Medical Council of India. The Indian medical graduate that is envisaged in this document should radically change the way UG teaching is done. However, there is no clarity on how this new curriculum will be implemented, decentralized and assessment systems modified, to suit the new curricular goals.

Accepting the reality of the social status that goes with the PG degree, the number of available PG seats should be increased to equal the number of UG seats. However, 50% of the PG seats should be for family practice, and policy decisions should be made to make the qualification in Family Medicine attractive. One such decision could be to make it compulsory for recruitment to state health services.

 

The regulatory oversight provided by the MCI has not worked because a top-down approach rarely works effectively. Since the quality of an institution goes far beyond physical infrastructure and availability of personnel, a robust and transparent 360o accreditation system, which evaluates processes, systems and quality of the output (namely, the student), is urgently required. Mentoring for institutions that fail to meet standards and support for quality enhancement and innovation, should be introduced. Such a mechanism has been proposed in the new bill.

Acknowledging the need for a larger number of medical seats, the government has established 200 medical colleges since 2010. It has also shown great concern for equitable access as 92 of the 200 medical colleges are in the government sector. These include the establishment of multiple AIIMS and conversion by state governments of district hospitals into medical colleges. It must be borne in mind that such rapid expansion of colleges could compromise the quality of training, due to the shortage of faculty and the general reluctance of medical graduates to adopt teaching as a career.

The lower tuition fees in government colleges allows access to a wider section of society. It has been demonstrated that students from rural and semi-rural backgrounds are far more likely to practice in those areas. Hence, the conversion of district hospitals to medical colleges should see some benefits in the coming years regarding manpower distribution.

It must be acknowledged that despite the increase in seats, the demand gap for medical services, especially in poorly served areas, may not be met in the near future. It would be more prudent to accept this and plan to deliver holistic health through reassignment of roles. An increased role for AYUSH practitioners, retraining of nurses as nurse practitioners, are among some such possibilities. However, attempts to introduce such initiatives have been strongly opposed by the IMA in the past. It would need a major change in the mindset of the medical profession which can only influence future generations of graduates through appropriate educational interventions.

The council must reinstate registration and ethical conduct as its core function. Lifetime registration must be changed to fixed term registration, with compulsory re-education programs associated with re-registration. This is essential in view of the rapid advances that are ongoing in medicine. Registration of PG degrees must be made compulsory to practice specialties. The processes for lodging complaints and dealing with them should be transparent. Malpractice issues must be considered by committees with adequate lay representation. Some of these measures are part of the newly proposed commission.

 

The gap between education and market expectations is the hallmark of the Indian education enterprise, and medical education is no exception. However, the medical profession is like no other as it is solely responsible for the health of the nation. Hence, there is the additional onus of responsibility to do it well and do it right. We need to recognize the issues and address them now if we are to look forward to a healthier nation in the near future.

 

Footnotes:

1. http://www.searo.who.int/entity/health_ situation_trends/countryprofile_ind.pdf? ua=1http

2. http://www.mciindia.org/ActsandAmend ments/TheIndianMedicalDegreeAct1916. aspx

3. https://old.mciindia.org/Actsand Amendments/AmendmentstotheAct.aspx

4. https://www.mciindia.org/CMS/information-desk/for-students-to-study-in-india/list-of-college-teaching-mbbs

5. Ibid.

6. http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee %20on%20Health%20and%20Family% 20Welfare/92.pdf

7. RRC Report, February 2015, GoI.

8. ://164.100.47.4/BillsTexts/LSBillTexts/Asintroduced/279_2017_Eng_LS.pdf

9. https://mohfw.gov.in/sites/default/files/9147562941489753121.pdf

10. http://www.who.int/gho/health_work-force/physicians_density/en/

11. Medical Council of India, Competency Based Undergraduate Curriculum for the Indian Medical Graduate, Delhi, 2018.