As of April 22, Uttar Pradesh has seen 1,449 cases of coronavirus disease (COVID-19) and accounts for 6.8% of the total cases in India. Of the 1,449 persons infected of the disease, 173 have recovered and 21 have died (3.1% of the total deaths in India due to the disease). These proportions are quite lower as compared to the state’s share in the country’s population (16.5% as per Census 2011). However, the same holds for the number of persons tested for COVID-19 as well, as of the 4.85 lakh persons tested in India, 37,490 persons (7.7%) have been tested in Uttar Pradesh.
To mitigate the spread of COVID-19 in the state, the state government has taken various measures over the past 2-3 months, spanning across areas such as health, law and order, and social welfare. This includes imposition of lockdown in 16 districts starting March 23, which was extended to the entire state on March 24, before the nation-wide lockdown came into effect. This blog post looks at the key measures taken by the state government in response to COVID-19 and the lockdown.
Before the lockdown
One of the earliest steps the state government took in response to COVID-19 was on January 27, when it planned to set up a 10-bed isolation ward in every district hospital and medical college, and increased vigilance on the Indo-Nepal border and airports. Subsequently, on March 15, it ordered all travellers coming from foreign countries to be kept under surveillance and quarantine for a period of 14 days. Between March 13 and March 17, the government ordered the closure of educational institutions, cinema halls, museums, and tourist spots to prevent public gatherings. On March 20, this was extended to include malls, and all religious, social, and cultural activities. Further, to prevent unnecessary crowding, government hospitals were ordered to provide emergency services only.
Welfare measures: The state government also undertook certain relief measures to provide aid to the persons affected due to COVID-19 and the consequent loss of economic activities. These include: (i) free treatment for all persons infected with COVID-19, (ii) order to all employers to provide 28-days paid leave to infected or quarantined persons under the Epidemic Diseases Act, 1897, (iii) another order under the Act to all shops and factories to provide paid leave to all workers if the government orders temporary closure of their business, (iv) free one-month ration to 1.65 crore registered construction workers and daily wage labourers for April, and (v) Rs 1,000 per month of direct cash support to 20.4 lakh registered construction workers, and to 15 lakh street vendors and other unregistered workers.
During the lockdown
During the lockdown, the state government’s measures have been aimed towards: (i) strengthening the medical response in the state, (ii) providing relief to various sections of the society from issues being faced during the lockdown, including UP migrants in other states, and (iii) addressing difficulties being faced in the supply of essential goods and services. For implementation of these measures, the government constituted 11 committees on March 26 for the work related to various departments. On April 13, similar committees were constituted under the respective Ministers.
Healthcare
Medical facilities: On March 23, committees were constituted in each district to determine the process for purchase of emergency medical equipment. On March 25, the government ordered each of the 51 government and private medical colleges in the state to set up isolation wards of 200-300 beds. It also proposed to conduct training programmes at district-level for AYUSH doctors, nursing staff, retired health workers, and officers of army medical corps. This was subsequently made more comprehensive by including lab technicians, ward boys, and sweepers.
Testing: On April 3, the government ordered setting up one testing lab in every medical college, or in a district hospital, in case there is no medical college in the district. On April 20, the government decided to encourage the use of pool testing within the state to contain the spread of COVID-19. It also approved consideration of plasma therapy as a treatment option for COVID-19.
Funding: On April 3, the UP COVID Care Fund was set up for strengthening treatment facilities in medical colleges, and for expenditure on personal protection equipment, test kits, ventilators, isolation and quarantine wards, and telemedicine. Subsequently, two Ordinances were promulgated on April 8 to deduct the salaries and allowances of Ministers, MLAs, and MLCs for 2020-21 by 30% to donate Rs 20 crore to the UP COVID Care Fund. Further, Rs 1,509 crore was made available for the Fund by suspending the Local Area Development scheme for legislators for a period of one year. In addition, the government increased the limit of the Contingency Fund from Rs 600 crore to Rs 1,200 crore through an Ordinance to allow for extra-budgetary expenditure on COVID-19 related measures.
Hotspots: On April 8, the government sealed the hotspot areas across the state by prohibiting any movement in the area. Only medical, sanitisation, and doorstep delivery teams are allowed to enter and exit the hotspot areas, and all enterprises are required to be completely closed. The government has also ordered for door-to-door checking of the residents living in hotspot areas.
Essential goods and services
Other than the distribution of ration, the state government is providing food to persons staying in night shelters, with community kitchens being set up for persons who are unable to cook. On April 17, the government made access to the Public Distribution System (PDS) universal till June 30, irrespective of the availability of ration card and Aadhaar card. In case of death of a person, his ration card, maintenance allowance, and other benefits will be provided to his family as per their eligibility.
To prevent profiteering from sale of essential goods, on March 28, the government ordered the shopkeepers to display the price list in their shops. On March 29, the government decided that the supply of electricity and water will be ensured and these connections will not be cut for one month. Subsequently, it also ordered that fixed charges for electricity will not be levied for industries during the period of lockdown. On April 3, the government ordered banks to remain open on holidays so that government relief assistance is available to the beneficiaries.
Migrants
From other states: On March 26, the state government decided that migrant workers travelling through the state to other states such as Bihar will be provided food and shelter, and sent safely to their destination. Subsequently, on March 28, the government decided to prepare the list of migrants who came to the state, provide them food, and keep them under surveillance and quarantine. On April 22, the government allowed migrants from other states to go back to their home state if the respective state government decides to take them back.
From UP: The state government requested other states to provide food and shelter to the migrants from UP present in their states, and requested the migrants to stay where they are. To provide further support to migrants, the state government appointed senior administrative and police officials as nodal officers for each state where migrants from UP might be present. These nodal officers are the main points of contact for migrants living in the respective states. They are also responsible for coordinating with the respective state government and local administration to ensure the essential needs of migrants such as food and shelter are met, and alleviate their difficulties, if any.
On April 19, the government brought nearly 8,000 students who were studying in Kota back to the state. The government allowed them to be kept in quarantine in their homes provided they download the Aarogya Setu app.
Economy
The state government is encouraging the purchase of produce by Farmer Producer Organisations directly from farms as an alternate option to mandis. On April 13, the government formed a committee of officials to prepare a workplan for attracting investment made by countries such as USA and Japan, which is moving out of China, to the state. In this regard, the government is planning to contact the embassies of various countries. On April 19, it constituted another committee to work towards providing employment to about 5 lakh migrant workers who have returned to the state in the last 45 days. On April 20, the government also allowed construction work on expressway projects to begin after preparation of an action plan. In line with the advisories issued by the central government, the state government decided to provide relaxations from the lockdown in districts with less than 10 cases starting April 20. The district administrations are preparing action plans for opening up industries in these districts, excluding the ones situated in the hotspot areas.
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.
