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.
A Bill to amend the Lokpal and Lokayuktas Act, 2013 was introduced and passed in Lok Sabha yesterday. The Bill makes amendments in relation to the declaration of assets of public servants, and will apply retrospectively. Declaration of assets under the Lokpal Act, 2013 The Lokpal Act, 2013 provides for a mechanism to inquire into corruption related allegations against public servants. The Act defines public servants to include the Prime Minister, Union Ministers, Members of Parliament, central government and Public Sector Undertakings employees, and trustees and officials of NGOs that receive foreign contribution above Rs 10 lakhs a year, and those getting a certain amount of government funding. [A June 2016 notification set this amount at Rs. 1 crore.] The Lokpal Act mandates public servants to declare their assets and liabilities, and that of their spouses and dependent children. Such declarations must be filed by July 31st every year. They must also be published on the website of the Ministry by August 31st. 2014 amendments proposed to the Lokpal Act In December 2014, a Bill to amend the 2013 Act was introduced in Lok Sabha. Among other things, the Bill sought to modify the provision related to declaration of assets by public servants. The Bill required that the public servant’s declaration contain information of all his assets, including: (i) movable and immovable property owned, inherited, acquired, or held on lease in his or another’s name; and (ii) debts and liabilities incurred directly or indirectly by him. The Bill also said that declaration requirements for public servants under the Representation of the People Act, 1951 (for MPs), All India Services Act, 1951 (for senior civil servants), etc. would also apply. The Standing Committee that examined this Bill, in 2015, had recommended that the public servants should declare the assets and liabilities to their Competent Authority. For example, for an MP, the competent authority would be the Speaker of Lok Sabha or Chairman of Rajya Sabha. Such declarations should then be forwarded to the Lokpal to keep in a fiduciary capacity. Both these authorities would be competent to review the returns filed by the public servants. In light of such double scrutiny, the Committee recommended that public disclosure of such assets and liabilities would not be necessary. Further, the Committee also noted that family members of public servants are not obliged to disclose assets acquired through their own income. These disclosures may be in violation of Article 21 (right to privacy) or 14 (right to equality) of the Constitution. However, the public servant must declare assets and liabilities of his dependents, and those acquired by him in the name of another. This Bill is currently pending in Lok Sabha. The 2016 Bill and its position on declaration of assets The Amendment Bill, that was introduced and passed by Lok Sabha yesterday, replaces the provision under the Lokpal Act, 2013 related to the declaration of assets and liabilities by public servants. While the new provision also mandates public servants to declare their assets and liabilities, it does not specify the manner of such declaration. The Bill states that the form and manner of such declarations to be made by public servants will be prescribed by the central government. Therefore, if passed by Parliament, the effect of the amendments will be the following:
These implications will apply only if the Bill is passed by Rajya Sabha and gets the President’s assent before July 31, 2016.
