The Indian Government recently promulgated the Indian Medical Council (Amendment) Ordinance, 2018. The 2018 ordinance supersedes the Medical Council of India (MCI), regulator for the medical profession, with a government-appointed Board of Governors for a period of one year, beginning September 26, 2018.
It has for the most part been hailed as a key precedent for bringing radical changes in the regulation of the medical profession in India. It is not.
The MCI has a long history of failures. Between 2000 and 2018, the MCI was under suspension for about 13 of the 18 years. It has been placed under the supervision of five court and government-appointed bodies, between 2001-07, 2010-13, 2016-17, 2017-18 and most recently for 2018-19.
These externally-appointed bodies have not been able to manage the affairs of MCI. For instance, both the oversight committees appointed by the Supreme Court of India, in 2016 and 2017, have cited various occurences of non-compliance of instructions by the MCI.
These long periods of suspension have yielded no reform in the functioning of MCI. Four proposals for reform have been made, none have seen the light of day:
1) The Indian Medical Council (Amendment) Bill, 2005 proposed to reduce the proportion of elected members and increase the accountability of MCI to the central government. The Parliamentary Standing Committee rejected the proposal in 2006 on the ground that it undermines the autonomy and democratic nature of MCI.
2) The National Commission for Human Resources for Health Bill, 2011 sought to overhaul the regulation of medical education through the proposed National Commission for Human Resources for Health (NCHRH); it left the regulation of professional conduct of all health professions to government-appointed central and state councils.The Standing Committee rejected the proposal, in 2012, on the ground that it undermines the autonomy and democratic setup of health profession regulators, including the MCI.
3) The Indian Medical Council (Amendment) Bill, 2013 proposed to reduce the term of the president and vice-president, prescribe conditions for their removal and increase the accountability of MCI to the central government.The Standing Committee rejected the proposal, in 2013, on the ground that it gave the government sweeping powers to control the MCI, thereby reducing its autonomy.
4) The National Medical Commission Bill, 2017 seeks to replace the MCI with the National Medical Commission (NMC). Notably, the 2017 Bill proposes to reduce the size of the regulator and provide some representation to patient interest in the NMC Board (three out of 25 members). However, the NMC will continue to be dominated by doctors (20 out of 25 members).
The Parliamentary Standing Committee, in 2018, recommended increasing the proportion of doctors and elected medical practitioners in the NMC, to make it representative and democratic.
The first proposal was ultimately withdrawn, while the second, third and fourth proposals are pending before the Parliament. In all four cases, the Parliamentary Standing Committee has emphasised the need for a democratic and representative setup of MCI. This is despite the fact that the MCI, elected by and composed entirely of doctors, failed to regulate medical education and has shown reluctance in disciplining doctors. A fact also recognised by the Parliamentary Standing Committee in 2016.
Professional regulators, around the world, have moved away from protecting the interests of the profession, to protecting and promoting public interest. International experience shows medical regulatory boards, dominated by doctors, are no longer considered desirable. In other countries, like the UK, Australia and California (USA), medical boards have substantial representation of patient interest. This was neither the case for MCI, nor will it be for the proposed NMC, which will also be dominated by doctors (20 out of 25 members).
While plans for reforming MCI are in limbo, regulation of the medical profession is suffering, most visible in the state of medical education in India. As an example, private and government medical colleges are being recognised and de-recognised by multiple authorties. In 2017, 32 medical colleges cleared by the Supreme Court-appointed oversight committee, were later banned by the government.
In 2018, the government banned another 82 medical colleges all over India: Uttar Pradesh lost 2,100 undergraduate medical seats, Karnataka lost 1,210 seats, Maharashtra lost 350 seats and Bihar almost lost 250 seats; they were subsequently allowed by the Supreme Court of India to take admissions. While the affected medical colleges seem unclear about the reasons for being banned, medical students are left in a lurch in the middle of their education. Some medical colleges, especially in rural areas, have started facing shortage of faculty. In a country facing an acute dearth of doctors, such state of affairs is worrying, to say the least. The longer it continues, the problem of shortage will become worse.
There is an urgent need for setting in place systems to facilitate adequate availability of qualified and competent doctors, in wake of the recently-launched Ayushmaan Bharat Scheme. It entails thinking about the structure and composition of the regulator (governing the medical profession), to ensure its independence and impartiality. The regulator should have well-defined legislative (by setting standards), executive (by enforcing prescribed standards) and judicial (by adjudicating violations of prescribed standards) functions. It should be designed with internal safeguards and processes to ensure accountability and transparency in its functioning.
Emergency measures, like the 2018 ordinance, which do not provide long-term solutions, are only leading us from the frying pan into the fire.
Shefali Malhotra is a consultant at the National Institute of Public Finance and Policy (NIPFP).