The National Medical Commission (NMC) Bill, 2017 was introduced in Lok Sabha in December, 2017. It was examined by the Standing Committee on Health, which submitted its report during Budget Session 2018. The Bill seeks to regulate medical education and practice in India. In this post, we analyse the Bill in its current form.
How is medical education and practice regulated currently?
The Medical Council of India (MCI) is responsible for regulating medical education and practice. Over the years, there have been several issues with the functioning of the MCI with respect to its regulatory role, composition, allegations of corruption, and lack of accountability. For example, MCI is an elected body where its members are elected by medical practitioners themselves, i.e. the regulator is elected by the regulated. In light of such issues, experts recommended nomination based constitution of the MCI instead of election, and separating the regulation of medical education and medical practice. They suggested that legislative changes should be brought in to overhaul the functioning of the MCI.
To meet this objective, the Bill repeals the Indian Medical Council Act, 1956 and dissolves the current Medical Council of India (MCI) which regulates medical education and practice.
Who will be a part of the NMC?
The NMC will consist of 25 members, of which at least 17 (68%) will be medical practitioners. The Standing Committee has noted that the current MCI is non-diverse and consists mostly of doctors who look out for their own self-interest over larger public interest. In order to reduce the monopoly of doctors, it recommended that the MCI should include diverse stakeholders such as public health experts, social scientists, and health economists. In other countries, such as the United Kingdom, the General Medical Council (GMC) responsible for regulating medical education and practice consists of 12 medical practitioners and 12 lay members (such as community health members, and administrators from the local government).
How will the issues of medical misconduct be addressed?
The State Medical Council will receive complaints relating to professional or ethical misconduct against a registered doctor. If the doctor is aggrieved by the decision of the State Medical Council, he may appeal to the Ethics and Medical Registration Board, and further before the NMC. Appeals against the decision of the NMC will lie before the central government. It is unclear why the central government is an appellate authority with regard to such matters.
It may be argued that disputes related to ethics and misconduct in medical practice may require judicial expertise. For example, in the UK, the GMC receives complaints with regard to ethical misconduct and is required to do an initial documentary investigation. It then forwards the complaint to a Tribunal, which is a judicial body independent of the GMC. The adjudication and final disciplinary action is decided by the Tribunal.
What will the NMC’s role be in fee regulation of private medical colleges?
In India, the Supreme Court has held that private providers of education have to operate as charitable and not for profit institutions. Despite this, many private education institutions continue to charge exorbitant fees which makes medical education unaffordable and inaccessible to meritorious students. Currently, for private unaided medical colleges, the fee structure is decided by a committee set up by state governments under the chairmanship of a retired High Court judge. The Bill allows the NMC to frame guidelines for determination of fees for up to 40% of seats in private medical colleges and deemed universities. The question is whether the NMC as a regulator should regulate fees charged by private medical colleges.
A NITI Aayog Committee (2016) was of the opinion that a fee cap would discourage the entry of private colleges, therefore, limiting the expansion of medical education. It also observed that it is difficult to enforce such a fee cap and could lead medical colleges to continue charging high fees under other pretexts.
Note that the Parliamentary Standing Committee (2018) which examined the Bill has recommended continuing the current system of fee structures being decided by the Committee under the chairmanship of a retired High Court judge. However, for those private medical colleges and deemed universities, unregulated under the existing mechanism, fee must be regulated for at least 50% of the seats. The Union Cabinet has approved an Amendment to increase the regulation of fees to 50% of seats.
How will doctors become eligible to practice?
The Bill introduces a National Licentiate Examination for students graduating from medical institutions in order to obtain a licence to practice as a medical professional.
However, the NMC may permit a medical practitioner to perform surgery or practice medicine without qualifying the National Licentiate Examination, in such circumstances and for such period as may be specified by regulations. The Ministry of Health and Family Welfare has clarified that this exemption is not meant to allow doctors failing the National Licentiate Examination to practice but is intended to allow medical professionals like nurse practitioners and dentists to practice. It is unclear from the Bill that the term ‘medical practitioner’ includes medical professionals (like nurses) other than MBBS doctors.
Further, the Bill does not specify the validity period of this licence to practice. In other countries such as the United Kingdom and Australia, a licence to practice needs to be periodically renewed. For example, in the UK the licence has to be renewed every five years, and in Australia it has to renewed annually.
What are the issues around the bridge course for AYUSH practitioners to prescribe modern medicine?
The debate around AYUSH practitioners prescribing modern medicine
There is a provision in the Bill which states that there may be a bridge course which AYUSH practitioners (practicing Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) can undertake in order to prescribe certain kinds of modern medicine. There are differing views on whether AYUSH practitioners should prescribe modern medicines.
Over the years, various committees have recommended a functional integration among various systems of medicine i.e. Ayurveda, modern medicine, and others. On the other hand, experts state that the bridge course may promote the positioning of AYUSH practitioners as stand-ins for allopathic doctors owing to the shortage of doctors across the country. This in turn may affect the development of AYUSH systems of medicine as independent systems of medicine.
Moreover, AYUSH doctors do not have to go through any licentiate examination to be registered by the NMC, unlike the other doctors. Recently, the Union Cabinet has approved an Amendment to remove the provision of the bridge course.
Status of other kinds of medical personnel
As of January 2018, the doctor to population ratio in India was 1:1655 compared to the World Health Organisation standard of 1:1000. The Ministry of Health and Family Welfare stated that the introduction of the bridge course for AYUSH practitioners under the Bill will help fill in the gaps of availability of medical professionals.
If the purpose of the bridge course is to address shortage of medical professionals, it is unclear why the option to take the bridge course does not apply to other cadres of allopathic medical professionals such as nurses, and dentists. There are other countries where medical professionals other than doctors are allowed to prescribe allopathic medicine. For example, Nurse Practitioners in the USA provide a full range of primary, acute, and specialty health care services, including ordering and performing diagnostic tests, and prescribing medications. For this purpose, Nurse Practitioners must complete a master’s or doctoral degree program, advanced clinical training, and obtain a national certification.
In India, children in the age group of 6-14 years have the right to free and compulsory elementary education in a neighbourhood school under the Right of Children to Free and Compulsory Education (RTE) Act, 2009. This covers primary (classes 1-5) and upper primary (classes 6-8) levels, which collectively constitute elementary education.
Amongst several provisions focused on elementary education, the Act provides for the No Detention Policy. Under this, no child will be detained till the completion of elementary education in class 8. The RTE (Second Amendment) Bill, 2017, introduced recently, revisits the No Detention Policy. In light of this, we discuss the No Detention Policy and issues affecting the implementation of RTE.
What is the No Detention Policy?
The rationale for the No Detention Policy or automatic promotion to the next class is minimising dropouts, making learning joyful, and removing the fear of failure in exams.[1] The evaluation mechanism under the Policy is the Continuous and Comprehensive Evaluation (CCE) for holistic assessments (e.g., paper-pencil test, drawing and reading pictures, and expressing orally) as opposed to the traditional system of examinations. CCE does not mean no evaluation, but it means an evaluation of a different kind from the traditional system of examinations.
What does the RTE (Second Amendment) Bill, 2017 propose to do?
The Bill proposes a ‘regular examination’ which will be held in class 5 and class 8 at the end of every academic year.[2] In the event that a child fails these examinations, he will be given remedial instruction and the opportunity for a re-examination.
If he fails in the re-examination, the central or state governments may choose: (i) to not detain the child at all, or (ii) to detain the child in class 5, class 8, or in both classes. This is in contrast to the current Policy where a child cannot be detained until the completion of class 8.
Conversation around the No Detention Policy
Following the implementation of the No Detention Policy, experts have recommended rolling it back partially or fully. The reasons for this reconsideration include: (i) the lack of preparedness of the education system to support the Policy, (ii) automatic promotion disincentivising children from working hard, (iii) low accountability of teachers, (iv) low learning outcomes, and (iii) the lack of proper implementation of CCE and its integration with teacher training.1,[3],[4]
In 2015, all the states were asked to share their views on the No Detention Policy. Most of the states suggested modifications to the Policy in its current form.
What do the numbers say?
Consequent to the enactment of RTE, enrolment has been 100% at the primary level (see Figure 1). While enrolment has been universal (100%) at the primary level, low transition of students from one class to another at progressively higher levels has been noted. This has resulted in high dropouts at the secondary education level, with the highest dropout rate being 17% at the class 10 level (see Figure 2).
Figure 1: Enrolment in elementary education (2005-2014)
One of the reasons for low dropouts at the elementary level may be the obligation to automatically promote and not detain children under the No Detention Policy. However, there is no such obligation on the government to provide for the same post class 9 i.e., in secondary education. The reasons which explain the rise in dropouts at the secondary level include domestic activities for girls and economic activities for boys, reasons common to both include financial constraints and lack of interest in education.[5]
Figure 2: Dropout rates in school education (2014-15)
How does RTE ensure quality education?
Based on the high enrolment and low dropout rates in elementary education, it can be inferred that children are being retained in schools for longer. However, there have been some adverse observations regarding the learning outcomes of such children. For example, the Economic Survey 2015-16 pointed out that only about 42% of students in class 5 (in government schools) are able to read a class 2 text. This number has in fact declined from 57% in 2007.[6] The National Achievement Survey (2015) for class 5 has also revealed that performance of students, on an average, had gone down from the previous round of the survey conducted in 2014.[7]
Key reasons attributed to low learning levels are with regard to teacher training and high vacancies.7,[8],[9] Against a total of 19 lakh teacher positions sanctioned under Sarva Shiksha Abhiyan in 2011-12, only 12 lakh were filled. Further, approximately 4.5 lakh untrained teachers were operating in 19 states. Teacher training institutes such as District Institutes of Education and Training are also experiencing high vacancies with regard to trainers who train teachers.[10]
It has also been noted that the presence of contract/temporary teachers, instead of permanent teachers, contributes to the deterioration of quality of education. In fact, experts have recommended that to ensure quality secondary education, the reliance on contract/temporary teachers must be done away with. Instead, fully qualified teachers with salary and benefits must be hired.[11] It has also been recommended that teachers should not be burdened with ancillary tasks of supervising cooking and serving of mid-day meals.10
The RTE Act, 2009 sought to ensure that teachers acquire minimum qualifications for their appointment, within five years of its enactment (i.e. till March 31, 2015). Earlier this year, another Bill was introduced in Parliament to amend this provision under the Act. The Bill seeks to extend this deadline until 2019.
In sum, currently there are two Bills seeking to amend the RTE Act, which are pending in Parliament. It remains to be seen, how they impact the implementation of the Act going forward.
[1] “Report of CABE Sub Committee on Assessment on implementation of CCE and no detention provision”, 2015, Ministry of Human Resource Development, http://mhrd.gov.in/sites/upload_files/mhrd/files/document-reports/AssmntCCE.pdf
[2] The RTE (Second Amendment) Bill, 2017.
[3] Change in No-Detention Policy, Ministry of Human Resource Development, March 9, 2017, Press Information Bureau.
[4] Unstarred question no. 1789, Ministry of Human Resource Development, Rajya Sabha, December 1, 2016.
[5] “Key Indicators of Social Consumption in India: Education”, NSS 71st Round, 2014, http://mail.mospi.gov.in/index.php/catalog/160/related_materials
[6] Economic Survey 2015-16, Ministry of Finance, http://indiabudget.nic.in/budget2016-2017/es2014-15/echapter-vol2.pdf
[7] National Achievement Survey, Class V (Cycle 3) Subject Wise Reports, 2014, http://www.ncert.nic.in/departments/nie/esd/pdf/NationalReport_subjectwise.pdf
[8] “253rd Report: Demands for Grants 2013-14, Demand No. 57”, Department of School Education and Literacy, Standing Committee on Human Resource Development, April 26, 2013, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20HRD/253.pdf
[9] “285th Report: Action Taken Report on 250th Report on Demands for Grants 2016-17”, Department of School Education and Literacy, Standing Committee on Human Resource Development, December 16, 2016, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20HRD/285.pdf
[10] “283rd Report: The Implementation of Sarva Shiksha Abhiyan and Mid-Day-Meal Scheme’, Department of School Education and Literacy, Standing Committee on Human Resource Development, December 15, 2016, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20HRD/283.pdf
[11] “Report of the CABE Committee on Girls’ education and common school system”, Ministry of Human Resource Development, 2005, http://mhrd.gov.in/sites/upload_files/mhrd/files/document-reports/Girls%20Education.pdf
