Disclaimer: The opinions expressed here are my own, and are based on my understanding of the motivation(s) behind the NMC Bill. 

Recently, the National Medical Commission Bill was tabled in the Lok Sabha (lower house of Parliament). This lead to nation-wide protests against the said Bill, and it has now been referred to a Standing Committee.

Background information:

The Medical Council of India (MCI) was established with the mandate to oversee medical education in India. Although it was supposed to operate as an independent body, the IMC Act reduced its role substantially, by decreeing that decisions had to be approved by the Government beforehand.

Over time, several committees were tasked the job of assessing/ remedying the prevailing situation with respect to medical education and training. However, their recommendations remained just that. This resulted in the development of several problems pertaining to medical education in particular, and health-care provision in general:

• Disproportionate distribution of modern medicine graduates in urban areas
• Lack of emphasis on primary care, resulting in graduates unsuitable to provide such care
• Overall deterioration in quality of medical education, and lack of standardization (MBBS graduates differ in skills based on the institution of training- there is no minimum assured standard for an MBBS graduate).
• No updation of medical curriculum in years- plans to overhaul the curriculum to a competence based approach remain a pipe dream
• Emphasis on infrastructure; head count; and equipment, rather than quality of teaching, etc.

The suggestion to replace the MCI with a new body dates back to 2006, when the National Knowledge Commission’s Working Group on Medical Education submitted its report .

Most of the suggestions of the Working Group were incorporated into the Preliminary Report of the Committee on the Reform of the Indian Medical Council Act, 1956 released in 2016. It was this Report that first proposed the establishment of the NMC, and drafted the NMC Bill 2016.

Although the latter document does not elaborate on the rationale/ justification(s) behind the provisions of the proposed NMC, the former does. We will examine both documents, and the NMC Bill 2017 document to understand what the intentions of the NMC Bill possibly are.

I will restrict this series of articles to major concerns/ claims about the NMC Bill, since it is not possible to discuss the Bill at length here.

Key Concern:

Bridge course for AYUSH practitioners

What the NMC Bill 2017 says:

Clause #49 (1): There should be a joint sitting of the Commission, the Central Council of Homeopathy, and the Central Council of Indian Medicine at least once a year.

Clause #49 (3) & (4):

Note:

#1. The above provisions require a unanimous decision on the part of all members for either development of ‘specific educational modules’, or ‘specific bridge course’ mentioned therein.

#2. The last line of sub-section (4) is most informative:
“to enable them to prescribe such modern medicines at such level as may be prescribed.”

This clearly indicates that the intention is to (If there is a unanimous decision among the members) allow AYUSH practitioners to prescribe only certain modern medicines, that too, at specified level(s) only- perhaps primary and/or secondary level.

Any claim that this grants parity to AYUSH practitioners following a bridge course is clearly untrue. (In simple terms, this does not indicate that AYUSH practitioners will be equal/ equivalent to MBBS graduates after successful completion of a bridge course. At best, they will be legally permitted to prescribe some modern medicines in specified situations- if such a decision is unanimously approved by all members, that is.)

Supporting evidence for Note#2:

Clause 2 (j) defines ‘medicine’ as ‘modern scientific medicine’

Clause 31 (1) states that a National Register containing the name and qualifications of all licensed medical practitioners shall be maintained.

Clause 31 (6) states that every State Medical Council should maintain a State Register, and update particulars every three months.

Clause 31 (8) addresses the question of AYUSH practitioners who may have passed the bridge course:

The fact that a separate National Register is to be maintained for such bridge course qualified AYUSH practitioners emphasizes the point that they will not have parity with MBBS graduates even if such a bridge course is implemented.

Rationale

Based on available documents mentioned previously, the rationale is:
I. There is a significant rural-urban divide; a majority of modern medicine graduates prefer to work in urban areas, whereas the majority of India’s population resides in rural areas. Several approaches have been tried to overcome this situation:

1. Coercion (rural service bond)
2. Increasing the number of public health cadre to offset the shortfall in doctors
3. Introduction of LMPs (Chhatisgarh)

None of the above measures succeeded. Graduates found ways to avoid their rural service, or left immediately upon its completion. Whenever possible, graduates protested the requirement, and often succeeded in obtaining concessions in this regard. Similarly, when the government of Chhatisgarh proposed the introduction of LMPs to address the situation, the IMA ensured that the plan was shelved. Andhra Pradesh’s experiment with public health cadre did not succeed either.

II. Due to the demand-supply gap, many AYUSH practitioners (who were already in rural areas) used the opportunity to prescribe modern medicines. This is not permitted under law, but there is no mechanism to control it.

III. ASHA workers and Public Health Nurses are permitted to dispense some medicines after training. AYUSH practitioners can also be trained to do the same- this is where the ‘bridge course’ comes in.

IV. There have been several calls- mostly ignored- to integrate systems of medicine in the past. However, there are concerted efforts to mainstream AYUSH, and AYUSH practitioners are now bonafide members of the healthcare system.

V. State governments are reluctant to appoint MBBS graduates as they cost considerably more to the exchequer; and often do not stay long enough in areas of need, citing lack of facilities, poor pay, etc.

Assumptions:

1. Following the implementation of a bridge course, AYUSH practitioners will legitimately fill the gap left by the MBBS graduates in rural areas by providing scientifically sound treatment (however limited).
2. This will help provide appropriate health care to many more than at present.
3. It will be illegal for AYUSH practitioners to prescribe modern medicines beyond those permitted; or if they haven’t passed the bridge course.

Additional comments:

The proposed ‘solution’ to address the healthcare needs of India’s rural population is far from perfect. However, in the absence of credible alternatives that work, this compromise is hoped to make a lot of difference.

The government is concerned with the health of all its citizens. If, for some reason or other, MBBS graduates are unavailable/ unsuitable to fulfill that mandate, it is the government’s prerogative to find alternatives to deliver the same.

The current situation has arisen due to decades of apathy shown by MBBS graduates towards rural healthcare. If they are unwilling, those who are willing should be utilized. Demands to ensure that MBBS graduates retain their ‘superiority’ over AYUSH practitioners are self-serving, and will do nothing to change the ground reality of rural healthcare in India.

It is possible that the move may have unintended consequences. However, since all previous measures have failed, there isn’t much to lose.

Further reading and References:

Report of the Working Group on Medical Education (available from:
http://knowledgecommissionarchive.nic.in/downloads/documents/wg_med.pdf)

Preliminary Report of Niti Ayog Committee on Reform of Indian Medical Council Act, 1956 (available from:
http://niti.gov.in/writereaddata/files/document_publication/MCI%20Report%20.pdf)

The National Medical Commission Bill 2017 (available from:
http://164.100.47.4/BillsTexts/LSBillTexts/Asintroduced/279_2017_Eng_LS.pdf)