Doctors and activists across the country say NMC Act will corporatise medical education and lower the quality of healthcare providers
The mood was belligerent among doctors on August 1. The Indian Medical Association (IMA), which represents the fraternity in the country, proclaimed that no doctor would attend to patients in emergency. Leading hospitals and medical institutions such as the All India Institute of Medical Sciences (AIIMS) in Delhi had, by this time, withdrawn from emergency services, apart from out-patient and in-patient departments.
As patients suffered and relatives bustled to find just about any medical practitioner for treatment, doctors were out on the streets protesting the passage of the National Medical Commission (NMC) Bill 2019 in the Lok Sabha on July 29.
This was one of the biggest strikes called by the medical fraternity. Senior doctors, medical students, medical associations as well as public policy experts joined hands to oppose it. Amid protests, Rajya Sabha too passed the bill. On August 8, the President signed it making it a law.
The government hails the NMC Act 2019 as a “historic” reform much needed for the country’s health education and practice. It repeals the Indian Medical Council Act, 1956.
The new body, called MCI, will replace the Medical Council of India (MCI) which was dissolved in 2010 following corruption charges against its president Ketan Desai by the Central Bureau of Investigation. The Supreme Court too had declared that MCI was steeped in corruption.
While tabling the bill in the Lok Sabha on July 29, Union Health Minister Harsh Vardhan said NMC would improve access to quality and affordable medical education, and ensure adequate medical professionals. The new body will be responsible for assessing and approving medical colleges, conducting common MBBS (Bachelor of Medicine and Bachelor of Surgery) entrance and exit exams, and regulating medical course fees.
At present, medical education is riddled with a host of problems. An exploding number of colleges, their skewed distribution across the country, devaluation of merit in admission particularly in private institutions, high capitation fee, an alarming shortage of teachers, and poor internship supervisions are just a few of the several drawbacks in the system, as per a paper published in International Journal of Community Medicine and Public Health in 2016.
The Economic Survey tabled in Parliament shows that 60 per cent of the primary health centres in the country are running with just one doctor, while about 5 per cent have no doctor at all.
Doctors say NMC will aggravate the problems it envisages to solve. The most contentious provision in the Act is granting prescription power to a 0.3 million-strong cadre which it calls community health providers (CHPs). It gives CHPs the licence to prescribe medicines at primary and preventive levels.
According to the Act, CHP is “a person connected with modern scientific medical profession”. This means, anyone, be it a laboratory technician, a blood sample collector, or even a compounder can now work as a doctor, says Vinay Kumar, president of the Resident Doctors’ Association at Patna Medical College and Hospital.
“MBBS students study for five years for a graduation degree. They invest many more years in higher education. They start practising after this. The new Act makes us wonder if there is any need for the toil at all,” he says.
When NMC Bill was sent to the 31-member Parliamentary Standing Committee on January 4 in 2018, it had no provision for CHPs. Doctors say the provisions was introduced slyly.
First tabled in Lok Sabha on December 29, 2017, the bill was studied by the standing committee headed by Rajya Sabha member Ram Gopal Yadav. It submitted its report to Parliament on March 16, 2018.
“The government had then said Ayush doctors would be allowed to practice modern medicine,” said Jairam Ramesh, Congress Member of Parliament who is also a member of the standing committee. “Thank God, the ministry went back on its proposal. But it ended up replacing one dangerous cocktail with another. Are we now going towards institutionalised quackery?”
The step to create a cadre of paramedics at a time when the country faces shortage of qualified doctors sounds logical. But such experiments have rarely yielded the intended results in the past, unless regulated well. The concept of CHPs is inspired from the Chinese government’s “barefoot doctors” experiment in the 1960s.
The government gave farmers basic training in medical and paramedical practices so that they could provide healthcare in rural areas where trained doctors hesitated to settle.
A 2008 study by The Lancet shows it took only a few years for China to realise that the barefoot doctors were focusing more on economic benefits than on curing diseases. The titles were, therefore, cancelled. T Sundararaman, a public health expert, considers the government’s effort to instate CHPs good only if the system is “heavily regulated”.
The CHPs should work only under the government. “The moment they are allowed to work privately, it would lead to corruption and defeat the purpose,” he says. Doctors have always resisted giving powers to people with short duration medical training such as community health workers.
That regulation is crucial is evident in Chhattisgarh and Assam which started a three-year diploma course for science graduates in 2001 and 2003 respectively. The passouts were designated the title of rural medical practitioner and were mandated to work only in rural areas in the government sector.
The programme showed remarkable success. The Central government has also mooted a law on allied and healthcare professionals on these lines. “Had the concept of CHPs been conceptualised on similar lines, it would have been an ideal concept,” says K S Srinath Reddy, president of Public Health Foundation of India.
Another provision in the Act may well diminish the quality of doctors the country produces, say doctors. It proposes that in the final year, an MBBS student will have to sit for only one exam called the National Exit Test (NEXT). This will be treated as the entrance test for postgraduation, give students the licence to practice, and also work as the screening test for students who graduate in medicine from foreign medical colleges. However, this crucial exam will test students on the basis of Multiple Choice Questions (MCQs).
The standing committee recommendation states that the final year exam should be held in a way that it takes into account the students’ cognitive domain and assesses their skills. It roots for “case study type questions” that will help them in the long run. It is unlikely that case study type questions will be converted into MCQs.
A major contentious issue is regulating tuition fee for medical education at a time when the private sector is widening its footprint. The existing system allows private colleges to fix high fees which triggered the mushrooming of private colleges.
The country has 537 medical colleges. The private medical colleges alone offer 40,000 MBBS seats. Karnataka, a hub for medical institutes, has only 19 government colleges but 40 private ones; Kerala has 10 government and 24 private colleges; and, Telangana has 10 government and 22 private colleges.
In 2014, the unregulated and prohibitive capitation fee in private medical colleges was contested in the Supreme Court. In July 2018, the apex court ordered the formation of a committee that would provide an appropriate fee structure to private colleges. After this, state governments formed committees and decided upper limits to their tuition fees. Eighty to 100 per cent seats in private colleges were regulated.
However, the NMC Act is likely to revert the efforts of the government and the Supreme Court. The Act says NMC will frame guidelines to regulate fee for a maximum of 50 per cent of the seats. This, say protesting doctors, will in fact opened the floodgates of privatisation and corporatisation. “This no-holds-barred situation is grave,” warns Sundararaman.
The institutional mechanism being brought in does not inspire confidence in mitigating malpractices, say some health experts. The new Medical Assessment and Rating Board can authorise a third party to inspect institutions for quality assessment, making way for corruption. Ironically, MCI that conducts assessments at present, is also charged with corruption.
The Act, however, does make an effort to rein-in the mushrooming of private colleges. “No person shall establish a new medical college or start any postgraduate course or increase number of seats without obtaining prior permission of the Medical Assessment and Rating Board,” it says.
If implemented properly, this provision can help fix the skewed distribution of colleges. At present, states with high population have few medical colleges, while states with less population have several of them. Of the 80,000-odd MBBS seats countrywide, Maharashtra has 8,580, Tamil Nadu has 7,145, Karnataka has 9,145 and Gujarat has 5,190 seats.
But in populated states like Bihar and Madhya Pradesh, that also have high mortality and morbidity rate, there are only 1,740 and 3,470 seats respectively. Small wonder, while Bihar has 40,649 doctors, Maharashtra has 175,000, Karnataka 123,000 and Tamil Nadu 136,000.
With the institution of NMC, the role of the state government will be reduced drastically—from being in the governance to a merely advisory one. The Act envisages the formation of the 33-member NMC with 10 state government representatives and nine doctors who are members of the state medical councils.
These will be given rotational membership in the commission for a term of two years. This means if a state is represented once, the next chance to do so would come only after eight years. For the state councils, the time gap would be bigger. At present, every state gets representation without any rotational arrangement.
The Centre will also have the power to remove the chairperson or any other member of the commission. “This reeks of the Centre’s obsession with power,” says Sundararaman. The Act talks about the creation of Medical Advisory Council, which will advise the NMC. This council will comprise 103 members. Would it be possible to reach a consensus on any issue with the such an overwhelmingly large body?
While the medical fraternity is angry with the changes, the government, “after many major deliberations realised that the idea of a self-regulatory body was not fruitful. NMC will bring a very transparent era in medical education with eminent personalities running it,” Arun Singhal, additional secretary, Ministry of Health and Family Welfare, told media after the bill was passed by both the Houses.
THE DEBATE OVER the NMC Act’s potential to reform medical sector has laid bare several uncomfortable realities about the country’s fast-growing higher technical education sector.
The sector banks on the top scorers, assures to train them for all kinds of high-paying, most sought-after jobs, right from engineering, computer programming and pharmacy to architecture, town planning and hotel management, and charges a premium for it. But does it deliver on the promise?
“There is a mismatch between the demand of the industry and the courses being imparted,” said Lok Sabha MP Shashi Tharoor during a discussion in Parliament about the All India Council for Technical Education’s (AICTE’s) new decision to not allow new conventional disciplines with low employment potential from academic year 2020-21.
While Tharoor took a dig at Prime Minister Narendra Modi by saying if the mismatch is removed then students will not have to be advised to “fry pakoras” to gain employment, his concerns can be explained by the abysmally low placement percentage of the country’s technical institutes.
In 2017-18, just 46 per cent of the 1.5 million students who graduated from various AICTE-accredited technical institutes managed to secure a job. The placement share was 45 per cent for engineering and technology graduates who, on an average, account for three-fourths of the technical students in the country.
The employment situation is pitiable for students of vocational centres like the Industrial Training Institutes (ITIs). India Skills Report 2019, published by online skill assessment firm Wheebox and the Confederation of India Industry, says more than 70 per cent of the students in ITIs and polytechnic institutes were unemployable in 2018. Their unemployment percentage was 53 per cent just four years ago.
This is a worrying trend at a time when India’s demography is fast changing with a heavy concentration of young population — some 130 million youth in the age group of 17-23 years. Most of them are seeking employment through skill-based education.
The government also has an ambitious target of increasing the gross enrolment ratio (GER) — number of enroled students as a percentage of the total population corresponding to the same level of education — in higher education to 30 per cent by 2020-21 from 25.8 per cent in 2017-18. This would significantly increase the demand for higher education in technical subjects, with 24 million new prospective enrolments.
Additionally, India’s GER for secondary education has crossed over 50 per cent, which will translate into additional demand for higher skill-based education.
Those associated with the sector say the current state of technical education in the country is ill-equipped to handle this growing demand. “Engineering colleges are unable to provide quality education,” says Dheeraj Sanghi, professor at the India Institute of Technology, Kanpur. He says most colleges do not have funds to hire qualified teachers.
“I cannot maintain the 1:15 student-teacher ratio that the AICTE recommends. I resort to hiring part-time teachers who do not hold high degrees and cost less,” he says.
A 2018 AICTE report on engineering education in India reiterates the point when it says while the country has a huge infrastructure for engineering education, “quality and accredited technical education is required to cater to the next-generation of engineering skill requirements”.
Though agricultural education is not covered under AICTE, the country has the world’s largest network of institutes to train students in this highly skilled vocation. Yet, the sector fares no better than the technical education sector. Most agricultural institutes do not have a director and lack in adequate infrastructure.
In April 2017, the government launched the third phase of the Technical Education Quality Improvement Programme along with the World Bank. With a Rs 2,660 crore outlay, the programme gives funds to a few selected institutes in 19 states and union territories.
Sanghi says the funds give only momentary relief and instead, the government should “increase the basic budget for education.” In the absence of government funds, private technical institutes have mushroomed in the country. In 2019-20, close to 80 per cent of the AICTE-approved technical institutes were private.
“The quality of education in private engineering colleges is so poor that half of them should be closed down,” says JBG Tilak, former vice-chancellor of the National University of Educational Planning and Administration, Delhi. “With extremely poor quality teachers and highly inadequate infrastructure, these colleges are making an immense disservice to our youth and society.
Our regulation system is weak and allows rampant commercialisation. As a result, the number of colleges has increased rapidly to unsustainable levels that many have to get closed down or have admissions much below the sanctioned strength,” he says.
The poor education quality and a resultant lack of employability mean that students are unwilling to enrol in technical institutes. In 2018-19, just 54 per cent of the 3.4 million seats available in the 10,426 AICTE-accredited technical institutes were filled. The enrolment share in private colleges stood at just 50 per cent that year.
The poor enrolment of students is also partly due to the skewed distribution of technical colleges. Just three states have more than 1,000 technical institutes — Maharashtra (1,558), Tamil Nadu (1,337) and Uttar Pradesh (1,264) — and they together account for close in 40 per cent of the 10,423 AICTE-approved technical institutes in the country in 2018-19. As a result, 18 of the 35 states and union territories, which include all the northeastern states and Delhi, had less than 100 technical institutes in 2018-19.
THERE IS ANOTHER side to the un-employability story of these over a million engineering graduates that India produces every year. The country’s manufacturing sector has slowed down.
“Colleges are now shifting to non-traditional engineering courses, such as artificial intelligence, the Internet of Things and the Cloud technology to cater to the market rush. But they do not teach students some basic engineering courses like mechanics. We need to inculcate analytical and problem solving skills in students,” says S S Mantha, former chairperson, AICTE.
A similar problem can be seen in the agriculture sector where a majority of the students switch over to other professions as they see no future in agriculture. “We need a system that encourages the infusion of original ideas to solve the problem,” says Avinash Kishore, an agriculture researcher with the Inter-national Food Policy Research Institute (IFPRI).
“For instance, students of agriculture should be encouraged to become entrepreneurs. But we do not have adequate infrastructure to promote them,” he says, adding that agriculture institutes have barely carried out new research since the mid-1990s.
In fact, the budget allocated for the Department of Agriculture Research Education, that promotes agricultural research and education in the country, has reduced drastically over the years—from 0.6 per cent of the agricultural GDP in 2010 to 0.4 per cent in 2018.
Lack of research means, the current curriculum is outdated as it does not include important aspects such as climate change adaptation methods in agriculture. “Technical education makes sense only if the curriculum is upto date. This alone can improve the employability of students. But this requires additional funding and deliberate planning,” says Mantha.
EACH TIME A person pays tax on income, a part of it goes into funding education, including higher education. The Union government levies a cess of 2 and 1 per cent for school and higher education and research respectively.
At present, the entire budget for school and higher education is borne by this education cess. Some argue this as an indicator of the government’s stepmotherly treatment to this sector. In Union Budget 2019-20, the education sector received Rs 94,853 crore, of which higher education received Rs 38,317 crore.
This entire allocation was budgeted from the education cess. This means the government did not allocate anything from its revenue for education. This cess has been in place since 2004 to “supplement the budget allocation to raise it to the level of 6 per cent of GDP to fulfil the promise and meet the genuine requirements of education sector”. It turns out that the government has, in fact, substituted regular budgetary allocation with cess from income tax payers.
The Yashpal Committee, constituted in 2009 with the mandate of advising on “renovation and rejuvenation of the education sector”, identified the need for a “drastic overhaul” of the higher education system.
The committee concluded that if higher education was to be seen as an integrated whole, governance of professional education should not be separated from that of general education; there ought to be a “single, all-encompassing higher education authority” that can regulate the sector pan-India.
Nevertheless, there are hectic efforts to rescue the higher education sector in India. Though delayed, at least there are definitive government efforts. And it starts from the primary education to the higher education.
India is currently debating a draft of a new education policy. K Kasturirangan, chairperson of its drafting committee says, “We are going to reorganise the entire education regime to focus more on quality in higher education institutions.
And that is the need of the hour.” According to the policy draft, he informs, some 900 universities and 40,000 colleges will be merged into 15,000-odd large, well-resourced and multidisciplinary institutions.
Institutes for higher education would move towards becoming three types of universities—research universities which give equal impetus to research and teaching; teaching universities that will lay primary emphasis on teaching with significant focus on research; and autonomous degree granting colleges which will look into undergraduate education and research.
Kasturirangan has recommended Rs 20,000 crore for research in higher education institutions. This is aimed at fixing the absence of updated knowledge to make contemporary technical education suitable for new skills that are in demand. “We are hopeful that the policy will facilitate higher education reach its optimal level in the next ten years,” he adds.
On reforming the country’s education regulation regime, the government has already approved the Higher Education Commission of India (Repeal of University Grants Commission Act) Bill 2018. Though it was introduced in the last Lok Sabha, there are efforts to reintroduce it.
Going by this package of reforms, the Union Government will dissolve AICTE and the University Grants Commission and replace them with a single body, tentatively titled Higher Education Empowerment Regulation Agency.
As per the statements made by the Union Human Resource Development Minister, having a single statutory body for higher education will simplify and consolidate the mass of regulations and compliances that currently operate in the sector.
Way back in 2005, the National Knowledge Commission set up by the Union government suggested these drastic changes. Clearly, the Union government needs to act as the Indian technical education sector needs drastic reforms and more importantly, momentum.
(This article was first published in Down To Earth's print edition dated August 16-31, 2019)
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