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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.
The National Education Policy (NEP) 2020 was released on July 30, 2020. It will replace the National Policy on Education, 1986. Key recommendations of the NEP include: (i) redesigning the structure of school curriculum to incorporate early childhood care and education, (ii) curtailing dropouts for ensuring universal access to education, (iii) increasing gross enrolment in higher education to 50% by 2035, and (iv) improving research in higher education institutes by setting up a Research Foundation. In this blog, we examine the current status of education in the country in view of some of these recommendations made by the NEP.
Universal access to Education
The NEP states that the Right to Education Act, 2009 has been successful in achieving near universal enrolment in elementary education, however retaining children remains a challenge for the schooling system. As of 2015-16, Gross Enrolment Ratio was 56.2% at senior secondary level as compared to 99.2% at primary level. GER denotes enrolment as a percent of the population of corresponding age group. Further, it noted that the decline in GER is higher for certain socio-economically disadvantaged groups, based on: (i) gender identities (female, transgender persons), (ii) socio-cultural identities (scheduled castes, scheduled tribes), (iii) geographical identities (students from small villages and small towns), (iv) socio-economic identities (migrant communities and low income households), and (v) disabilities. In the table below, we detail the GER in school education across: (i) gender, and (ii) socio-cultural identities.
Table 1: GER in school education for different gender and social groups (2015-16)
|
Level |
Male |
Female |
SC |
ST |
All |
|
Primary (I-V) |
97.9% |
100.7% |
110.9% |
106.7% |
99.2% |
|
Upper Primary (VI-VIII) |
88.7% |
97.6% |
102.4% |
96.7% |
92.8% |
|
Secondary (IX-X) |
79.2% |
81% |
85.3% |
74.5% |
80% |
|
Senior Secondary (XI-XII) |
56% |
56.4% |
56.8% |
43.1% |
56.2% |
Sources: Educational Statistics at Glance 2018, MHRD; PRS.
Data for all groups indicates decline in GER as we move from primary to senior secondary for all groups. This decline is particularly high in case of Scheduled Tribes. Further, we analyse the reason for dropping out from school education. Data suggests that the most prominent reason for dropping out was: engagement in domestic activities (for girls) and engagement in economic activities (for boys).
Table 2: Major reasons for dropping out (Class 1-12) for 2015-16
|
Reason for dropping out |
Male |
Female |
|
Child not interested in studies |
23.8% |
15.6% |
|
Financial Constraints |
23.7% |
15.2% |
|
Engage in Domestic Activities |
4.8% |
29.7% |
|
Engage in Economic Activities |
31.0% |
4.9% |
|
School is far off |
0.5% |
3.4% |
|
Unable to cop-up with studies |
5.4% |
4.6% |
|
Completed desired level/ Class |
5.7% |
6.5% |
|
Marriage |
|
13.9% |
|
Other reasons |
5.1% |
6.2% |
Note: Other reasons include: (i) timings of educational Institution not suitable, (ii) language/medium of Instruction used unfamiliar, (iii) inadequate number of teachers, (iv) quality of teachers not satisfactory, (v) unfriendly atmosphere at school. For girl students, other reasons also include: (i) non-availability of female teachers, (ii) non-availability of girl’s toilet.
Sources: Educational Statistics at Glance 2018, MHRD; PRS.
The NEP recommends strengthening of existing schemes and policies which are targeted for such socio-economically disadvantaged groups (for instance, schemes for free bicycles for girls or scholarships) to tackle dropouts. Further, it recommends setting up special education zones in areas with significant proportion of such disadvantaged groups. A gender inclusion fund should also be setup to assist female and transgender students in getting access to education.
Increasing GER in Higher Education to 50% by 2035
The NEP aims to increase the GER in higher education to 50% by 2035. As of 2018-19, the GER in higher education in the country stood at 26.3%. Figure 2 shows the trend of GER in higher education over the last few years. Note that the annual growth rate of GER in higher education in the last few years has been around 2%.
Figure 1: GER in Higher Education (2014-15 to 2018-19)
Sources: All India Survey on Higher Education, MHRD; PRS.
Table 3: Comparison of GER (higher education) with other countries
|
Country |
GER (2017-18) |
|
India |
25% |
|
Brazil |
51% |
|
China |
49% |
|
Indonesia |
36% |
|
South Africa |
22% |
|
Pakistan |
9% |
|
Germany |
70% |
|
France |
66% |
|
United Kingdom |
60% |
Sources: UNESCO; PRS.
The NEP recommends that for increasing GER, capacity of existing higher education institutes will have to be improved by restructuring and expanding existing institutes. It recommends that all institutes should aim to be large multidisciplinary institutes (with enrolments in thousands), and there should be one such institution in or near every district by 2030. Further, institutions should have the option to run open distance learning and online programmes to improve access to higher education.
Foundational literacy and numeracy
The NEP states that a large proportion of the students currently enrolled in elementary school have not attained foundational literacy and numeracy (the ability to read and understand basic text, and carry out basic addition and subtraction). It recommends that every child should attain foundational literacy and numeracy by grade three.
Table 4 highlights the results of the National Achievement Survey 2017 on the learning levels of students at Grade 3 in language and mathematics. The results of the survey suggest that only 57% students in Grade 3 are able to solve basic numeracy skills related to addition and subtraction.
Table 4: NAS results on learning level of Grade-3 students
|
Learning level (Grade 3) |
Percentage of students |
|
Ability to read small texts with comprehension (Language) |
68% |
|
Ability to read printed scripts on classroom walls such as poems, posters (Language) |
65% |
|
Solving simple daily life addition and subtraction problems with 3 digits (Mathematics) |
57% |
|
Analyses and applies the appropriate number operation in a situation (Mathematics) |
59% |
Sources: National Achievement Survey (2017) dashboard, NCERT; PRS.
To achieve universal foundational literacy and numeracy, the Policy recommends setting up a National Mission on Foundational Literacy and Numeracy under the MHRD. All state governments must prepare implementation plans to achieve these goals by 2025. A national repository of high-quality resources on foundational literacy and numeracy will be made available on government’s e-learning platform (DIKSHA). Other measures to be taken in this regard include: (i) filling teacher vacancies at the earliest, (ii) ensuring a pupil to teacher ratio of 30:1 for effective teaching, and (iii) training teachers to impart foundational literacy and numeracy.
Effective governance of schools
The Policy states that establishing primary schools in every habitation across the country has helped increase access to education. However, it has led to the development of schools with low number of students. The small size of schools makes it operationally and economically challenging to deploy teachers and critical physical resources (such as library books, sports equipment).
With respect to this observation, the distribution of schools by enrolment size can be seen in the table below. Note that, as of September 2016, more than 55% of primary schools in the country had an enrolment below 60 students.
Table 5: Distribution of schools by enrolment size
|
Strength (Grade) |
Below 30 |
31-60 |
61-90 |
91-120 |
121-150 |
151-200 |
More than 200 |
|
Primary schools (Class 1-5) |
28.0% |
27.5% |
16.0% |
10.3% |
6.3% |
5.6% |
6.4% |
|
Upper primary schools (Class 6-8) |
14.8% |
27.9% |
18.7% |
15.0% |
8.4% |
7.2% |
8.0% |
|
Upper primary schools (Class 1-8) |
5.7% |
11.6% |
13.0% |
12.1% |
10.4% |
13.4% |
33.8% |
Sources: Flash Statistics on School Education 2016-17, UDISE; PRS.
While nearly 80% primary schools had a library, only 1.5% schools had a librarian (as of September 2016). The availability of facilities is better in higher senior secondary schools as compared to primary or upper primary schools.
Table 6: Distribution of schools with access to physical facilities
|
Facilities |
Primary schools (Class 1-5) |
Upper primary schools (Class 1-8) |
Higher senior secondary |
|
Library |
79.8% |
88.0% |
94.4% |
|
Librarian |
1.5% |
4.5% |
34.4% |
|
Playground |
54.9% |
65.5% |
84.3% |
|
Functional computer |
4.4% |
25.2% |
46.0% |
|
Internet connection |
0.9% |
4.2% |
67.9% |
Sources: Flash Statistics on School Education 2016-17, UDISE; PRS.
To overcome the challenges associated with development of small schools, the NEP recommends grouping schools together to form a school complex. The school complex will consist of one secondary school and other schools, aanganwadis in a 5-10 km radius. This will ensure: (i) adequate number of teachers for all subjects in a school complex, (ii) adequate infrastructural resources, and (iii) effective governance of schools.
Restructuring of Higher Education Institutes
The NEP notes that the higher education ecosystem in the country is severely fragmented. The present complex nomenclature of higher education institutes (HEIs) in the country such as ‘deemed to be university’, ‘affiliating university’, ‘affiliating technical university', ‘unitary university’ shall be replaced simply by 'university'.
According to the All India Survey on Higher Education 2018-19, India has 993 universities, 39,931 colleges, and 10,725 stand-alone institutions (technical institutes such as polytechnics or teacher training institutes).
Table 7: Number of Universities in India according to different categories
|
Type of university |
Number of universities |
|
Central University |
46 |
|
Central Open University |
1 |
|
Institutes of National Importance |
127 |
|
State Public University |
371 |
|
Institution Under State Legislature Act |
5 |
|
State Open University |
14 |
|
State Private University |
304 |
|
State Private Open University |
1 |
|
Deemed University- Government |
34 |
|
Deemed University- Government Aided |
10 |
|
Deemed University- Private |
80 |
|
Total |
993 |
Sources: All India Survey on Higher Education 2018-19; PRS.
The NEP recommends that all HEIs should be restructured into three categories: (i) research universities focusing equally on research and teaching, (ii) teaching universities focusing primarily on teaching, and (iii) degree granting colleges primarily focused on undergraduate teaching. All such institutions will gradually move towards full autonomy - academic, administrative, and financial.
Setting up a National Research Foundation to boost research
The NEP states that investment on research and innovation in India, at only 0.69% of GDP, lags behind several other countries. India’s expenditure on research and development (R&D) in the last few years can be seen in the figure below. Note that the total investment on R&D in India as a proportion of GDP has been stagnant at around 0.7% of GDP. In 2018-19, the total expenditure on R&D in India was Rs 1,23,848 crore. Of this, Rs 72,732 crore (58%) of expenditure was by government, and the remaining (42%) was by private industry.
Figure 2: R&D Expenditure in India (2011-12 to 2018-19)
Sources: S&T Indicators Table 2019-20, Ministry of Science and Technology, March 2020; PRS.
Figure 3: Comparison of R&D expenditure in India with other countries (2017)
Sources: S&T Indicators Table 2019-20, Ministry of Science and Technology, March 2020; PRS.
To boost research, the NEP recommends setting up an independent National Research Foundation (NRF) for funding and facilitating quality research in India. The Foundation will act as a liaison between researchers and relevant branches of government as well as industry. Specialised institutions which currently fund research, such as the Department of Science and Technology, and the Indian Council of Medical Research, will continue to fund independent projects. The Foundation will collaborate with such agencies to avoid duplication.
Digital education
The NEP states that alternative modes of quality education should be developed when in-person education is not possible, as observed during the recent pandemic. Several interventions must be taken to ensure inclusive digital education such as: (i) developing two-way audio and video interfaces for holding online classes, and (ii) use of other channels such as television, radio, mass media in multiple languages to ensure reach of digital content where digital infrastructure is lacking.
In this context, we analyse: (i) the availability of computer and internet across households in India, and (ii) ability to use computer or internet by persons in the age group of 5-14. As of 2017-18, the access to internet and computer was relatively poor in rural areas. Only 4.4% of rural households have access to a computer (excludes smartphones), and nearly 15% have access to internet facility. Amongst urban households, 42% have access to internet.
Table 8: Access to Computer and Internet across households (2017-18)
|
Access to ICT |
Rural |
Urban |
Overall |
|
Households having computer |
4.4% |
23.4% |
10.7% |
|
Households having internet facility |
14.9% |
42.0% |
23.8% |
Note: Computer includes desktop, laptop, notebook, tablet. It does not include smartphone.
Sources: Household Social Consumption on Education (2017-18), Ministry of Statistics and Programme Implementation, July 2020; PRS.
Table 9: Ability to use Computer and Internet across persons in the age group 5-14 (2017-18)
|
Ability to use ICT |
Rural |
Urban |
Overall |
|
Ability to use computer |
5.1% |
21.3% |
9.1% |
|
Ability to use internet |
5.1% |
19.7% |
8.8% |
Note: Ability to use computer means to be able to carry out any of the tasks such as: (i) copying or moving a file/folder, (ii) sending emails, (iii) transferring files between a computer and other devices, among others. Ability to use internet means to be able to use the internet browser for website navigation, using e-mail or social networking applications.
Sources: Household Social Consumption on Education (2017-18), Ministry of Statistics and Programme Implementation, July 2020; PRS.
Public spending on education to be increased to 6% of GDP
The recommendation of increasing public spending on Education to 6% of GDP was first made by the National Policy on Education 1968 and reiterated by the 1986 Policy. NEP 2020 reaffirms the recommendation of increasing public spending on education to 6% of GDP. In 2017-18, the public spending on education (includes spending by centre and states) was budgeted at 4.43% of GDP.
Table 10: Public spending on Education (2013-2018)
|
Year |
Public expenditure (Rs crore) |
% of GDP |
|
2013-14 |
4,30,879 |
3.84% |
|
2014-15 |
5,06,849 |
4.07% |
|
2015-16 |
5,77,793 |
4.20% |
|
2016-17 |
6,64,265 |
4.32% |
|
2017-18 |
7,56,945 |
4.43% |
Sources: 312th Report, Standing Committee on Human Resource Development, March 2020; PRS.
Figure 4: Comparison of public spending on Education in India with other countries as % of GDP (2015)
Sources: Educational Statistics at Glance 2018, MHRD; PRS.
In the figure below, we look at the disparities within states in education spending. In 2020-21, states in India have allocated 15.7% of their budgeted expenditure towards education. States such as Delhi, Rajasthan, and Maharashtra have allocated more than 18% of their expenditure on Education for the year 2020-21. On the other hand, Telangana (7.4%), Andhra Pradesh (12.1%) and Punjab (12.3%) lack in spending on education, as compared to the average of states.
Figure 5: Budgeted allocation on Education (2020-21) by states in India
Note: AP is Andhra Pradesh, UP is Uttar Pradesh, HP is Himachal Pradesh and WB is West Bengal.
Sources: Analysis of various state budget documents; PRS.
For a detailed summary of the National Education Policy, see here.
