Medical Education System In India

WHY IN NEWS?

• India’s medical education system has attracted a lot of adverse attention due to the crisis in Ukraine and the resultant need for evacuating medical students, delay in post-graduate counselling because of reservation-related litigation and Tamil Nadu legislating to opt out of NEET.

BACKGROUND:

• Despite having the most number of medical colleges in the world, and currently having approximately 9.29 lakhs doctors enrolled on the Indian Medical Register, India is way behind in achieving the targeted doctor population ratio of 1:1000 as per WHO norms.
• Shortage of doctors, who are the most important cog in the health care delivery system, has derailed both access to and quality of health care, especially to the vulnerable and poorer sections of the country.
• Besides acute shortage of medical doctors, there are serious issues concerning mal-distribution of doctors and imbalanced growth of medical colleges in the country.
• Though there have been substantial improvements in health outcomes over the years, there are  still large gaps in health care accessibility in many parts of the country and Universal Health Care still remains  a distant dream
• This indicates that India has not been able to leverage its economic growth to achieve the desired health outcomes

ISSUES IN MEDICAL EDUCATION SYSTEM:

• Demand-supply mismatch:
  • There is a serious demand-supply mismatch in medical college seats as well as inadequate seats in terms of population norms.
  • The very nature of medical education, an empirical field, requires significant infrastructure — land, equipment, and trained faculty at the post graduate level — all of which are in short supply and uneven in their spread.
  • Without correcting these deficiencies, India cannot expect to dramatically increase the availability of medical personnel.
• High fees in private colleges >> leading to outflow of students to foreign countries:
  • In private colleges in India, medical seats are priced between Rs 15-30 lakh per year. This is way more than what most Indians can afford.
  • Recent efforts by the National Medical Council (NMC) to regulate college fees are being resisted by medical colleges.
  • The most sought-after international destinations — traditionally, for medical education the U.S., the U.K. and a few west European countries — are also too expensive for most Indians.
  • In the last few decades, Russia, China and Ukraine, with their historical commitment to public health care have been able to offer more affordable, yet quality, education >> hence more Indian students are attracted to these destinations.
• Low doctor-patient ratio:
  • India has one government doctor for every 11,528 people and one nurse for every 483 people, which is way below WHO recommended 1:1000.
• Low return on investment
  • The MBBS degree continues to be an attractive option.
  • However, unlike in the past, a substantial section of the middle class no longer feels that this is a good return of investment
• Inequality in the distribution of resources:
  • Medical colleges in the country are distributed in a skewed manner >> with nearly sixty five per cent medical colleges concentrated in the Southern and Western States of the country which has resulted in great variation in doctor-population ratio across the States
  • There is also a glaring rural-urban disparity in both availabilities of health care and colleges.
• Out-dated syllabus and teaching style:
  • Regular breakthroughs take place in the medical field every day, but the medical studies syllabus in India is not updated accordingly.
• Lack of skilled teachers:
  • Teachers for medical institutes are selected based on their degrees and not their clinical experience.
  • Further, the lower salary fails to attract better talent as they go for private practice.
• Lack of social accountability:
  • Indian medical students do not receive training which instils in them social accountability as health practitioners.
• Commercialisation of medical education:
  • After liberalisation of 1990s >> made it easy to open private schools and so many such medical institutes cropped up in the country, funded by businessmen and politicians, who had no experience of running medical schools >> It commercialised medical education to a great extent.
• Corruption in medical education:
  • Fraudulent practices and rampant corruption such as fake degrees, bribes and donations, proxy faculties, etc. in the medical education system is a major problem.
• Focus on rote learning than clinical skills:
  • The fundamental exam pattern in the medical education has remained the same, banking on rote learning techniques, while their clinical skills are not tested till they start practicing.
• Failures of Medical Council of India (now scrapped):
  • Failure to create a curriculum that produces doctors suited to working  in  Indian  context especially in the rural health services and poor urban areas
  • Failure to maintain uniform standards of medical education, both undergraduate and post-graduate
  • Devaluation of merit in admission, particularly in private medical institutions due to prevalence  of  capitation  fees,  which  make  medical  education  available  only  to   the rich  and  not  necessarily  to  the  most  deserving
  • Failure  to  instill respect for  a  professional  code of  ethics in  the  medical professionals and take disciplinary action against doctors found violating the code of Ethic
  • Failure  to  create  a  transparent  system  of  medical  college  inspections  and  grant   of recognition  or  de-recognition
  • Failure to guide  setting  up  of  medical  colleges in  the  country as  per  need,  resulting in geographical mal-distribution of medical colleges  with  clustering  in  some  states  and  absence  in  several  other  states  and  the  disparity  in  healthcare  services  across states
  • Further, MCI was alleged of promoting Inspector Raj (that is, inspections carried out by the MCI to ensure the maintenance of required standards by medical colleges) and the malpractices linked with it.
  • Allegations of rampant corruption in the MCI.
• Concerns associated with National Medical Commission Act:
  • Centralisation of power:
    • Though health is primarily a state subject, the Act empowers the central government to give such directions and the state government shall comply with such directions.
  • Audit by Third Party:
    • The NMC Act proposed to set up a “Medical Assessment and Rating Board” to hire and authorise any other third-party agency or persons for carrying out inspections of medical institutions for assessing and rating such institutions.
    • The authenticity of quality audits by private bodies can be questioned.
  • Issue of Autonomy:
    • The Act provides NMC as a complete subsidiary of the government. From the selection of its office-bearers and members to its finances, its functioning and powers, all being comprehensively controlled by the government.
    • This absolute control of the government of the NMC, threatens its autonomy.
  • Legalized Quackery:
    • The Act is silent on the method by which the “commission” will grant “limited licence” to community health providers to practise modern medicine.
    • The absence of clarity on this front, may allow some unqualified personnel to perform duties of a medical practitioner.

• Issues with NEET:
  • There are allegations that NEET is infringing upon the state governments’ power to hold admissions in the medical colleges funded by them. (Recently Tamil Nadu Assembly has passed a Bill to dispense with the NEET)
  • Students from some of the state boards are at a disadvantage from progressive boards.
  • Students in rural India and those studying in state government-run schools seem to have a lesser chance of success.
  • These examinations do not test the attitude and aptitude of the students correctly.
  • There is more concentration of students from national boards clearing the exam.
  • At present a candidate can claim domicile in more than one state, which makes the admission process lengthy and allows scope for malpractices.
  • Promote Coaching Factories: The standardisation of exams will lead to mushrooming of Coaching institutes to bridge the gap in School education. This is seen in India with NEET and similar other national tests
  • Transparency: The NEET paper was leaked twice in the past. Therefore, there is not much confidence in NEET’s fairness and transparency.

KEY FEATURES OF NATIONAL MEDICAL COMMISSION ACT

• Constitution of the National Medical Commission:
  • The Act sets up the National Medical Commission (NMC).
  • State governments will establish State Medical Councils at the state level.
  • The NMC will consist of 25 members, appointed by the central government.
  • A Search Committee will recommend names to the central government for the post of Chairperson, and the part time members.
• Functions of the National Medical Commission:
  • (i) Framing policies for regulating medical institutions and medical professionals
  • (ii) Assessing the requirements of healthcare related human resources and infrastructure
  • (iii)Ensuring compliance by the State Medical Councils of the regulations made under the Bill
  • (iv)Framing guidelines for determination of fees for up to 50% of the seats in private medical institutions and deemed universities which are regulated under the Act
• Medical Advisory Council:
  • Under the Act, the central government will constitute a Medical Advisory Council.
  • The Council will be the primary platform through which the states/union territories can put forth their views and concerns before the NMC.
  • Further, the Council will advise the NMC on measures to determine and maintain minimum standards of medical education.
• Autonomous boards:
  • The Act sets up autonomous boards under the supervision of the NMC.
  • Each autonomous board will consist of a President and four members, appointed by the central government.
  • These boards are:
    • Under-Graduate Medical Education Board (UGMEB) and the Post-Graduate Medical Education Board (PGMEB):
      • These Boards will be responsible for formulating standards, curriculum, guidelines, and granting recognition to medical qualifications at the undergraduate and post graduate levels respectively.
    • The Medical Assessment and Rating Board (MARB):
      • MARB will have the power to levy monetary penalties on medical institutions which fail to maintain the minimum standards as laid down by the UGMEB and PGMEB.
      • The MARB will also grant permission for establishing a new medical college, starting any postgraduate course, or increasing the number of seats.
    • The Ethics and Medical Registration Board:
      • This Board will maintain a National Register of all licensed medical practitioners, and regulate professional conduct.
      • Only those included in the Register will be allowed to practice medicine.  The Board will also maintain a separate National Register for community health providers.
• Community health providers:
  • Under the Act, the NMC may grant a limited license to certain mid-level practitioners connected with the modern medical profession to practice medicine.
  • These mid-level practitioners may prescribe specified medicines in primary and preventive healthcare.
  • In any other cases, these practitioners may only prescribe medicines under the supervision of a registered medical practitioner.
• Entrance examinations:
  • 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 Act.
  • The NMC will specify the manner of conducting common counselling for admission in all such medical institutions.
• National Exit Test:
  • The Act proposes a common final year undergraduate examination called the National Exit Test for the 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 Act.

STEPS NEEDED TO REFORM MEDICAL EDUCATION:

• Converting district hospitals into medical colleges
  • NITI Aayog suggests rapid scale-up of seats by converting district hospitals into medical colleges using a private-public partnership model.
• Subsidising medical education for disadvantaged students
  • The government should seriously consider subsidising medical education, even in the private sector, or look at alternative ways of financing medical education for disadvantaged students. 
• Reforming existing guidelines for setting up medical colleges:
  • There is a pressing need to revisit the existing guidelines for setting up medical schools and according permission for the right number of seats.
• Regular Quality Assessments:
  • Quality assessments of medical colleges should be regularly conducted, and reports should be available in the public domain
• Facilitate private investment in the sector:
  • The private sector should be encouraged, along with cooperation from States, to set up more medical colleges and hospitals locally so that such aspirants remain in India.
• Learning from past mistakes:
  • Merely having private establishments start medical schools, without a long-term commitment to offer necessary training and post-graduate education, could lead to a repeat of the engineering fiasco after the dotcom boom: a surfeit of engineering colleges without adequately trained faculty or infrastructure that churn out students who need a further skills upgrade to be employable.
  • The Government must instead ease procedures for establishing medical colleges, spend more on infrastructure, and provide incentives for a health-care ecosystem to develop in rural areas.
• Medical manpower planning should be bottom-up:
  • Present approach in the matter of healthcare manpower planning is a top-down one.
  • Since health is a State subject and State Governments are major stakeholders in the delivery of healthcare services, medical manpower planning should be bottom- up.
• Term of a National Medical Commission member:
  • In line with the recommendation of the Roy Chaudhary Committee that a member of the Council may not have more than two-terms in office.
  • Such a provision will also bring a  blend  of experience and fresh thinking in the functioning of the regulatory body.
• Do not leave the sector completely to market forces:
  • Universal need and information asymmetry are among the many reasons often cited to make the case for the exclusion of market forces in health services and medical education
• Trained team of auditors:
  • Inspection should be done with doctors’ designated bodies to keep it corruption free.
• Focus on quality and societal needs
  • The current scaling up efforts, which are most welcome, are re-envisaged to focus on quality and societal needs along with commercial viability.

PRACTICE QUESTION:

Q. Private investment in medical education by itself will not solve the issues plaguing the sector. Comment