This post is pursuant to the discussion on population stabilization being held in Parliament currently. India is the second most populous country in the world, sustaining 16.7% of the world's population on 2.4% of the world's surface area. The population of the country has increased from 238 million in 1901 to 1,029 million in 2001. Even now, India continues to add about 26 million people per year. This is because more than 50% of the population is in the reproductive age group. India launched a family planning programme in 1952. Though the birth rate started decreasing, it was accompanied by a sharp decrease in death rate, leading to an overall increase in population. In 1976, the first National Population Policy was formulated and tabled in Parliament. However, the statement was neither discussed nor adopted. The National Health Policy was then designed in 1983. It stressed the need for ‘securing the small family norm, through voluntary efforts and moving towards the goal of population stabilization’. While adopting the Health Policy, Parliament emphasized the need for a separate National Population Policy. This was followed by the National Population Policy in 2000. The immediate objective of the policy was to address the unmet needs for contraception, health care infrastructure and personnel, and to provide integrated service delivery for basic reproductive and child health care. The medium-term objective was to bring TFR (Total Fertility Rate - the average number of children a woman bears over her lifetime) to replacement levels by 2010. In the long term, it targeted a stable population by 2045, ‘at a level consistent with the requirements of sustainable economic growth, social development, and environmental protection.’ (See http://populationcommission.nic.in/npp.htm) Total Fertility Rate India’s TFR was around 6.1 in 1961. This meant that an average woman bore over 6 children during her lifetime. Over the years, there has been a noticeable decrease in this figure. The latest National Family Health Survey (NFHS III, 2005-06) puts it at 2.7. TFR is almost one child higher in rural areas (3.0) than in urban areas (2.1). TFR also varies widely across states. The states of Andhra Pradesh, Goa, Himachal Pradesh, Karnataka, Kerala, Maharashtra, Punjab, Sikkim and Tamil Nadu have reached a TFR of 2.1 or less. However, several other states like UP, Bihar, MP, Rajasthan, Orissa, Uttaranchal, Jharkhand and Chhattisgarh, where over 40% of the population lives, TFR is still high. (See http://www.jsk.gov.in/total_fertility_rate.asp) Factors that affect population growth The overarching factor that affects population growth is low socio-economic development. For example, Uttar Pradesh has a literacy rate of 56%; only 14% of the women receive complete antenatal care. Uttar Pradesh records an average of four children per couple. In contrast, in Kerala almost every person is literate and almost every woman receives antenatal care. Kerala records an average of two children per couple. Infant mortality In 1961, the Infant Mortality Rate (IMR), deaths of infants per 1000 live births, was 115. The current all India average is much lower at 57. However, in most developed countries this figure is less than 5. IMR is the lowest at 15 in Kerala and the highest at 73 in Uttar Pradesh. Empirical correlations suggest that high IMR leads to greater desire for children. Early marriage Nationwide almost 43% of married women aged 20-24 were married before the age of 18. This figure is as high as 68% in Bihar. Not only does early marriage increase the likelihood of more children, it also puts the woman's health at risk. Level of education Fertility usually declines with increase in education levels of women. Use of contraceptives According to NFHS III (2005-06), only 56% of currently married women use some method of family planning in India. A majority of them (37%) have adopted permanent methods like sterilization. Other socio-economic factors The desire for larger families particularly preference for a male child also leads to higher birth rates. It is estimated that preference for a male child and high infant mortality together account for 20% of the total births in the country. Government initiatives The National Population Policy 2000 gave a focused approach to the problem of population stabilization. Following the policy, the government also enacted the Constitution (84th Amendment) Act, 2002. This Amendment extended the freeze on the state-wise allocation of seats in the Lok Sabha and the Rajya Sabha to 2026. It was expected that this would serve ‘as a motivational measure, in order to enable state governments to fearlessly and effectively pursue the agenda for population stabilization contained in the National Population Policy, 2000’. The National Commission on Population was formed in the year 2000. The Commission, chaired by the Prime Minister, has the mandate to review, monitor and give directions for implementation of the National Population Policy. The Jansankhya Sthirata Kosh (National Population Stabilization Fund) was setup as an autonomous society of the Ministry of Health and Family Welfare in 2005. Its broad mandate is to undertake activities aimed at achieving population stabilization. Programmes like the National Rural Health Mission, Janani Suraksha Yojana, ICDS (Integrated Child Development Services) etc. have also been launched by the government to tackle the healthcare needs of people. This is also expected to contribute to population stabilization. Free contraceptives are also being provided. In addition, monetary incentives are given to couples undertaking permanent family planning methods like vasectomy and tubectomy. Nutritional and educational problems are being targeted through programs like the mid-day meal scheme and the recently enacted Right to Education. ---------------- For more details on the issue, see the website of the National Population Stabilization Fund (http://www.jsk.gov.in/) Sources: Registrar General, India National Population Stabilization Fund National Commission on Population National Family Health Survey III (2005-06)
Today, the National Medical Commission Bill, 2019 was passed by Lok Sabha. It seeks to regulate medical education and practice in India. In 2017, a similar Bill had been introduced in Lok Sabha. It was examined by the Standing Committee on Health and Family Welfare, which recommended several changes to the Bill. However, the 2017 Bill lapsed with the dissolution of the 16th Lok Sabha. In this post, we analyse the 2019 Bill.
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. Experts have 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 MCI.
The 2019 Bill sets up the National Medical Commission (NMC) as an umbrella regulatory body with certain other bodies under it. The NMC will subsume the MCI and will regulate medical education and practice in India. Under the Bill, states will establish their respective State Medical Councils within three years. These Councils will have a role similar to the NMC, at the state level.
Functions of the NMC include: (i) laying down policies for regulating medical institutions and medical professionals, (ii) assessing the requirements of human resources and infrastructure in healthcare, (iii) ensuring compliance by the State Medical Councils with the regulations made under the Bill, and (iv) framing guidelines for determination of fee for up to 50% of the seats in the private medical institutions.
Who will be a part of the NMC?
The Bill replaces the MCI with the NMC, whose members will be nominated. The NMC will consist of 25 members, including: (i) Director Generals of the Directorate General of Health Services and the Indian Council of Medical Research, (ii) Director of any of the AIIMS, (iii) five members (part-time) to be elected by the registered medical practitioners, and (iv) six members appointed on rotational basis from amongst the nominees of the states in the Medical Advisory Council.
Of these 25 members, at least 15 (60%) are medical practitioners. The MCI has been noted to be non-diverse and consists mostly of doctors who look out for their own self-interest over public interest. In order to reduce the monopoly of doctors, it has been recommended by experts that the MCI should include diverse stakeholders such as public health experts, social scientists, and health economists. For example, in the United Kingdom, the General Medical Council which is responsible for regulating medical education and practice consists of 12 medical practitioners and 12 lay members (such as community health members, administrators from local government).
What are the regulatory bodies being set up under the NMC?
The Bill sets up four autonomous boards under the supervision of the NMC. Each board will consist of a President and four members (of which two members will be part-time), appointed by the central government (on the recommendation of a search committee). These bodies are:
How is the Bill changing the eligibility guidelines for doctors to practice medicine?
There will be a uniform National Eligibility-cum-Entrance Test for admission to under-graduate and post-graduate super-speciality medical education in all medical institutions regulated under the Bill. Further, the Bill introduces a common final year undergraduate examination called the National Exit Test for students graduating from medical institutions to obtain the license for practice. This test will also serve as the basis for admission into post-graduate courses at medical institutions under this Bill. Foreign medical practitioners may be permitted temporary registration to practice in India.
However, the Bill does not specify the validity period of this license to practice. In other countries such as the United Kingdom and Australia, a license to practice needs to be periodically renewed. For example, in the UK the license has to be renewed every five years, and in Australia it has to renewed annually.
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 medical practitioner. If the medical practitioner is aggrieved of a decision of the State Medical Council, he may appeal to the Ethics and Medical Registration Board. If the medical practitioner is aggrieved of the decision of the Board, he can approach the NMC to appeal against the decision. It is unclear why the NMC is an appellate authority with regard to matters related to professional or ethical misconduct of medical practitioners.
It may be argued that disputes related to ethics and misconduct in medical practice may require judicial expertise. For example, in the UK, the regulator for medical education and practice – the General Medical Council (GMC) receives complaints with regard to ethical misconduct and is required to do an initial documentary investigation in the matter and then forwards the complaint to a Tribunal. This Tribunal is a judicial body independent of the GMC. The adjudication decision and final disciplinary action is decided by the Tribunal.
How does the Bill regulate community health providers?
As of January 2018, the doctor to population ratio in India was 1:1655 compared to the World Health Organisation standard of 1:1000. To fill in the gaps of availability of medical professionals, the Bill provides for the NMC to grant limited license to certain mid-level practitioners called community health providers, connected with the modern medical profession to practice medicine. These mid-level medical practitioners may prescribe specified medicines in primary and preventive healthcare. However, in any other cases, these practitioners may only prescribe medicine under the supervision of a registered medical practitioner.
This is similar to 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.
