1. Clause 32: Limited License to practice at Mid-level as Community Health Provider:
India has a doctor-population ratio of 1:1456 as compared with the WHO standards of 1:1000. In addition, there is a huge skew in the distribution of doctors working in the Urban and Rural areas with the urban to rural doctor density ratio being 3.8:1. Consequently, most of our rural and poor population is denied good quality care leaving them in the clutches of quacks. It is worth noting that at present 57.3% of personnel currently practicing allopathic medicine does not have a medical qualification.
The ambitious Ayushman Bharat initiative announced by GoI in this year’s Budget Speech needs 1,50,000mid-level providers within the next 3-5 years to provide comprehensive primary and preventive care.It will take 7-8 years to ramp up the supply of doctors, therefore, in the interim we have no option but to rely upon a cadre of specially trained mid-level providers who can lead the Health and Wellness Centres.
There are international examples of Health Systems permitting such Community Health workers. Countries such as Thailand, United Kingdom, China, and even New York have permitted Community Health Workers/Nurse Practitioners into mainstream health services, with improved health outcomes. Since we haveshortage of doctors and specialists, the task shifting to Mid- level Provider will relieve the overburdened specialists. This is merely an enabling provision to grant limited licence only in primary and preventive healthcare to practice medicine at mid-level to such persons, who qualify such criteria as may be specified by regulations which will have an overwhelming representation of Doctors. Chhattisgarh and Assam have experimented with the Community Health Workers. As per independent evaluations (carried out by Harvard School of Public Health), they have performed very well and there is no ground of concern if the quality of personnel is regulated tightly.
2. Clause 15: NEXT Exam
Medical Education (ME) is a specialized area with high focus on technical skill sets. A common final year undergraduate examination (NEXT) withcommon standards of knowledge and skills for Doctors on a Nation-wide basis.
An enabling provision has been made to ensure common standards. Regulations for operationalizing the NEXT would be made in due course keeping in mind importance of both theoretical as well as clinical skill setsrequired at the level of UG. Composition of NMC includes 75% doctors representing Central and States Institutions/Councils and health universities. Such a composition of NMC will ensure that due weightage to theoretical as well as clinical skill sets is adhered to. There is a 3 year window before NEXT becomes operational, leaving ample scope for detailed negotiations on the contours of the exam.
3. Clause 10(1) (i): Fee regulation
IMC Act, 1956 has no provision for regulation of fees. As a result, some states regulate the fees of some seats in private colleges through MoUs signed with college managements. In addition, the Supreme Court has set up committees chaired by retired High Court Judges to fix fees in private colleges as an interim measure. Deemed to be Universities claim that they are not covered by these committees.
Nearly 50% of the total MBBS seats in the country are in government colleges, which have nominal fees. Of the remaining seats, 50% would be regulated by NMC. This means that almost 75% of total seats in the country would be available at reasonable fees. In the spirit of federalism, the State governments would still have the liberty to decide fees for remaining seats in private medical colleges on the basis of individual MOUs signed with colleges on the basis of mutual agreement.
States also have been providing scholarships on the basis of merit cum means and would normally continue to do so in order to make medical education affordable to all students. We need to balance the interests of the poor but meritorious students and the promoters of the private medical colleges in order to expand the number of seats on offer. It is not correct to assume that colleges would be free to arbitrarily raise the fees for unregulated seats. The transparency provided by NEXT results would lead to regulation of fees through market forces. Colleges would have to provide quality of education commensurate to the fees charged by them, otherwise there would be no takers for their management quota seats.
Rating would be provided by MARB for medical institutions based on the standard of education/training. This will serve to regulate fee through market forces.
Any affirmative action has to meet the test of reasonability. India has a large middle class population. The government of the day is duty bound to create infrastructure for all segments of society.
While we solicit private investment in the medical education sector and want private medical colleges to be financially viable, this government has not shied away from its responsibility to create more seats in the government sector. We have invested more than Rs 10,000 crores in creating government seats in the past five years, and are also setting up 21 new AIIMS at a cost of over Rs 30,000 crores to boost the medical education sector. This trend of creating government seats will continue in future.
There is no question of NMC Bill making medical education a preserve of the rich. On the contrary, it is common knowledge that before the reforms of NEET and common counseling were introduced by our government, rich students who could afford to pay huge and unrecorded capitation fees were able to secure admission to private medical colleges. Our reforms have eliminated the role of black money in medical education and the NMC Bill will provide statutory force to the reforms which have been carried out.
Another bogey which is being raised is that merit will be given a go by in the proposed dispensation. Nothing could be further from the truth. The earlier provision was that any student who obtains 50% marks at class 12 level could gain admission to MBBS courses. Colleges negotiated with students and conducted their own admission tests in a totally non-transparent manner. As a result, many undeserving students got admission. Now only NEET qualified students can get admission, which ensures that merit prevails in admissions.