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Critical Review of Report of the Parliamentary Standing Committee on Health


Dear Leaders,

Department-related parliamentary standing committee on health and family welfare has submitted the 92nd report to the Parliament on the functioning of the Medical Council of India.

The following is a critical review of the Key observations of the committee. (Part 1)

Observation 

2.10 The Committee observes that though there have been substantial improvements in certain health outcomes, especially in life expectancy, maternal and infant mortality, these achievements should not mask India's failures in achieving the desired level of health care delivery. 

As per the Report of the Working Group on Tertiary Care Institutions for the 12th  Five Year Plan, rates of infant and maternal deaths still remain high, nearly one million Indians die every year due to inadequate healthcare facilities, 700 million people have no access to specialist care and 80% of specialists are working in urban areas. Despite India's economy today being one of the world's fastest growing and third largest in terms of Gross National Health Income, our health system continues to face a huge need gap in terms of access to adequate healthcare and availability of health professionals and facilities. India also has the dubious distinction of lagging behind countries like Nepal, Bhutan, Bangladesh, Peru, Maldives, China, Brazil, Thailand, Sri Lanka and Chile on important health indicators including child mortality and maternal mortality. If 63 million persons are faced with poverty every year due to health care costs alone (as per Draft National Health Policy, 2015), it clearly indicates that health care is moving away from the reach of the people in general and the poor in particular. This also indicates that India has not been able to leverage its economic growth to achieve the desired health outcomes. The fact that there is an acute shortage of doctors in the country and the effective delivery of health care services cannot be guaranteed without the availability of doctors in adequate numbers, testifies to the point that the system of medical education, as regulated by the Medical Council of India, has not been able to address the many unmet health care needs of our health system and needs reforms urgently. 

Comment

The  conclusions of the PSC seems to have been derived solely on the basis of various representations and hearings. There seems to be lack of any ground level study or even making an attempt to get all the shades of opinion from all the stakeholders. Although the assessment of the health status in India is correct, the solution offered is not the right one. 

The health of the public depends on many social determinants such as safe drinking water, nutritious food, sanitation, environmental pollution etc. The focus for getting better standards of health has to be on 1. improving the social determinants 2. emphasis on health education and preventive aspects 3. building a health delivery team where the role of  doctors and also paramedics and health workers are equally important.  The report no where mentions about steps to improve the social determinants, preventive health initiatives or the need for para-medics and health workers. Whatever wrong that is happening in the health sector cannot be entirely put on the MCI. The total health workforce per population is more important determinant of health outcomes than mere doctor population ratio as is evident in many countries including SriLanka

Observation 

2.21 The Committee agrees that there is an acute shortage of medical doctors in the country besides their geographical mal-distribution. The Committee takes note of the submission of Ministry of Health and Family Welfare that the total number of doctors registered on the Indian Medical Register is 9.29 lakhs out of which 7.40 lakhs are available for active practice and that the doctor - population ratio in India is 1:1674 as against the WHO norm of 1:1000. However, given the fact that the Indian Medical Register is not a live database and contains names of doctors who may have passed away or retired from active practice, by now, as well as those with a permanent address outside India and that there is no mechanism in place for filtering out such cases, the Committee is highly sceptical of the Ministry's claim of having one doctor per 1674 population. In view of the above, the Committee feels that the total universe of doctors in India is much smaller than the official figure and we may have one doctor per 2000 population, if not more. The Committee observes that the imbalances in availability of affordable and quality health care cannot be corrected without augmenting the capacity of production of medical doctors including specialists and super-specialists in adequate numbers and of requisite quality and competence. Apart from the unfinished agenda of communicable diseases, India is witnessing the rapidly rising burdens of non-communicable diseases (Cardiovascular diseases, Cancer, Diabetes, Chronic respiratory disorders, Mental illness, Liver and Kidney diseases), which call for the availability of many more category of doctors and specialist doctors. The Committee is constrained to observe that the MCI has been unresponsive to health system needs with the result that shortage in number of basic doctors and specialists, mal- distribution of medical colleges and doctors across the states continue to plague the delivery of effective and equitable health services. At the present rate of production of doctors, the shortfall in basic and specialist doctors will not be met for many years. The Committee, therefore, recommends that urgent measures may be taken to spell out policy stance in great detail and with clarity to augment the capacity of production of doctors including specialists and super-specialists at the scale and speed required to meet India's health needs. 

Comment

It is surprising that the PSC has put the sole blame  of not producing more doctors on the MCI. The committee also has not taken into cognisance the fact that there are other streams of systems of medicine and they are doctors. First of all the govt should lay down a health policy as to the role of other systems of medicine (AYUSH). When NSS 2014 clearly states that only hardly 5% of the population seek medical help from AYUSH, the govt is increasingly spending scarce resources on promoting unwanted and unpopular systems of medicine. PSC has not commented on this. 

PSC must be aware that the role of MCI is limited to inspection of already sanctioned medical colleges. The powers of MCI has been gradually taken away since 1993, so much so it is a state govt which gives NOC to start a new medical college on which MCI has no role. MCI power is limited to only inspection. Even after inspection, on the basis of the inspection report it is the health ministry which sanctions/recognises the medical college.So blaming the MCI for shortage of doctors is not fair. Central govt has come out with a policy of starting medical colleges by converting each district hosp. it was assumed that these medical colleges will be govt medical colleges. Unfortunately the govt is promoting PPP model in starting medical colleges. E.g Govt has leased out the Raichur hospital to the Apollo Group and the 300-bed Chittoor district hospital in Andhra Pradesh to Apollo for five years for establishing medical colleges

Observation 

2.22 The Committee is concerned to note that the medical colleges in the country are distributed in a skewed manner, with nearly sixty five percent 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. The States of North, North-East and Central India have a severe shortage of doctors because of very few medical colleges they have. The Committee also notes with concern the that six states with 31% of India’s population account for 58% of the MBBS seats, while eight states which comprise 46% of India’s population have 21% of the MBBS seats. TheCommittee is of the opinion that the mere increase in medical seats to enable correction of this doctor-population imbalance will not automatically address this skew because experience shows that doctors normally settle in the cities they go to for their medical education and do not return to serve in their own urban or rural areas. Also, even if compulsory rural service is introduced throughout India, graduates of each state would be required to serve only in their state, as per present state health regulations, and the states with very few medical colleges would continue to be disadvantaged. The Committee would, therefore, recommend that an institutional mechanism be put in place to ensure better distribution of medical colleges across the country. State level doctor-population ratio should guide the setting up of new medical colleges and also the increase in UG and PG seats. 

Comment

The shortage of Doctors in the  rural areas can be solved by 1.  the method of selection of graduates by entrance examination without giving weightage to mark of the qualifying exam has resulted in cities centred and affluent students getting admission to MBBS course.  Only affluent students can afford the coaching classes which equip the students to face the MCQ exam. 

The proposed all indian common entrance(NEET) itself is weighed more towards affluent and city bases students. although conceptually NEET can ensure uniform standard of the med graduates, as a pre-requisite difference streams leading onto plus two like ICSE, CBSE, Pre-degree etc should be made into one common syllabi or curriculum 2. the shortage of doctors in very rural areas has to be addressed as a special problem and special solution has to be implemented by way of higher salary, facility for accomodation, transport, children’s education and reservation for post graduation 3. In many instances , the very situation of the PHCs are far away from the crowded population. if every railway station including in most remote areas can have a railway colony with residential accomodation, shops and even educational institutions, why cant every PHC have a mini-township approach  to accommodate doctors, para-medics, pharmacists health workers and others

Observation 

2.23 The Committee also observes that the 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 also. The Committee, accordingly, recommends that each State should plan for an optimal number of doctors, with a target of 1:1000 doctor-population ratio.

Comment

The PSC  should have recommended even amendment of the constitution as far as the Health Care Institutions are concerned and brought the establishments under one roof so that inter-state , trans-state appointments of doctors and paramedics could be made possible

Observation 

3.10 The Committee has carefully and comprehensively examined the issue of elected versus nominated regulator and done a rigorous analysis to evaluate whether the architecture of regulatory oversight for the medical profession in India should be elected or nominated one. 

3.11 The Committee observes that the main objective of the regulator of medical education and practice in India is to regulate quality of medical education, tailor medical education to the healthcare needs of the country, ensure adherence to quality standards by medical colleges, produce competent doctors possessing requisite skills and values as required by our health system and regulate medical practice in accordance with the professional code of ethics. The Medical Council of India, when tested on the above touchstone, has repeatedly been found short of fulfilling its mandated responsibilities. Quality of medical education is at its lowest ebb; the current model of medical education is not producing the right type of health professionals that meet the basic health needs of the country because medical education and curricula are not integrated with the needs of our health system; many of the products coming out of medical colleges are ill-prepared to serve in poor resource settings like Primary Health Centre and even at the district level; medical graduates lack competence in performing basic health care tasks like conducting normal deliveries; instances of unethical practice continue to grow due to which respect for the profession has dwindled. But the MCI has not been able to spearhead any serious reforms in medical education to address these gaps. 

3.12 Medicine deals with human life. Regulators are therefore, required to have the professional excellence and moral authority to address complex issues related to content, standards, quality, competencies and skills of medical education and practice. But the MCI, as presently elected, neither represents professional excellence nor its ethos. The current composition of the Council reflects that more than half of the members are either from corporate hospitals or in private practice. The Committee is surprised to note that even doctors nominated under Sections 3(1) (a) and 3(1) (e) to represent the State Governments and the Central Government have been nominated from corporate private hospitals which are not only highly commercialised and provide care at exorbitant cost but have also been found to be violating value frameworks. They indulge in unethical practices such as carrying out unnecessary diagnostic tests and surgical procedures in order to extract money from hapless patients and meet revenue targets (as documented by the BMJ, one of the top international medical journals in an article titled “The unethical revenue targets that India’s corporate hospitals set their doctors” dated 3, September, 2015) and flouting government rules and regulations, especially about treating patients from underprivileged backgrounds. 

3.13 The Committee also observes that the number of private medical colleges is growing and therefore their representation in the MCI is certain to increase while the Government representation will decrease in that proportion. In such a scenario, the needs of the country and the health system have taken a backseat while the interests of practicing doctors have become primary. Thus, the current composition of the MCI is biased against larger public health goals and public interest. 

3.14 The paramount consideration for the regulation of medical education should be to ensure that it safeguards the quality of medical education, well serves the needs of India's health system and enables the health needs of the people to be met. This is far more important than protecting the elected character of the regulatory framework. Electoral processes, by their very nature, bring about a lot of compromises and tend to attract professionals who may not be best-fitted for the heavy academic responsibilities of a regulatory body. It is, therefore, highly unlikely that professionals of the highest standards of eminence and integrity would be thrown up through electoral processes. The Committee feels that perhaps this is one of the reasons why election from within the profession has been discontinued around the globe. 

3.15 The Committee is, therefore, of the opinion that the governance of medical education in India must be accountable to the people of India. Ultimately, popularly elected governments are answerable to the people for the performance of the health system, not the MCI. Also, a regulatory body nominated by the government need not always be suspect in quality or subservient in conduct. Following the dissolution of a corruption-ridden MCI, the new Board of Governors of MCI appointed by the Government in 2010, included professionals of the highest standards of integrity and excellence who came up with a Vision Document 2015 wherein the Board had recommended a number of reforms of far-reaching impact in the field of medical education and practice. Similarly, the National Board of Examinations whose governing Board is nominated by the Ministry of Health and Family Welfare has acquitted itself creditably and has not been tainted by a scandal in its 33 years of history. TheCommittee also wonders that if none of the countries like the USA, U.K, Australia or Japan has elected regulatory body for medical education, why should India be the only one to have elected regulators for medical education. 

3.16 After serious reflection borne out of the above analysis and keeping in mind the disastrous experience with an elected regulatory body, the Committee is convinced that if the quality of medical education has to be maintained and medical profession disciplined in the context of mushrooming of private medical colleges and the resultant commercialisation of medical education, regulators of the highest standards of professional integrity and excellence will have to be sought by the Government through a rigorous selection process. The Committee, accordingly, recommends that the regulatory framework of medical education and practice should be comprised of professionals of the highest standards of repute and integrity, appointed through a rigorous and independent selection process. This process must be transparent. Nominations could be sought but the reason for the final selection should be made public. The Committee also concurs with the recommendation of the Ranjit Roy Chaudhury Committee Report that: 

"In keeping with global standards, and as is the practice in other educational fields in our country (AITCE and UGC) regulatory structure should be run by persons selected through a transparent mechanism rather than by the current process of election and nominations. Of course, keeping in mind the federal nature of the country, adequate provision must be made for the representatives of the States to participate in the regulatory processes.” 

Comment

Many of the arguments which have been mentioned to justify to convert MCI from an elected/nominated body to a purely nominate body are not convincing. The MCI has been converted to a truncated and powerless body by various amendments. For e.g, the amendment of curriculum and syllabi although the MCI has time and again bring about amendments in curriculum and syllabi for implementation there is already need for the govt ratification to enforce it. The amendments suggested by MCI way back in 2002 has not been ratified  by the govt. So its squarely the inaction of the govt that the revision of curriculum and syllabi are not taking place in time. 

In fact the MCI has to be strengthened by establishing a medical grants commission in the lines of UGC, setting up of an accreditation body as is happening with engineering and general education which oversees uniform and sustained standards in medical education and a committee to address the working conditions of medical teachers including pay and promoting research. Instead of bringing about such dynamic changes in MCI and medical education sector, replacing it with a nominatedcommittee will make MCI much more weaker. MCI has to function as a watch dog organisation which could remain vigil and even wet govt policies. converting MCI into a wing of the govt by nominating members will only cause further degeneration in the med education sector.  In fact the no. of elected representatives should be increased from the present 1 per state to 1 per 20,000 medical graduates. 

A committee of only professionals with the highest academic excellence cannot address and identify the health problems of people in the remotest parts of our country to which they are not exposed. Even the Board of governors appointed by the govt had more representatives from corporate sector. Other than bringing a vision statement, BoG during its existence for almost 5 years did not bring about any substantial improvement in the medical education sector including revision of syllabi and curriculum. To suggest that people of highest excellence shun election is a strong statement against democracy and gives a view that all elected representatives are second rate citizens.

So the recommendation for an entirely nominate MCI is a wrong solution

Observation

3.20 The Committee observes that currently the MCI is an exclusive club of medical doctors as the IMC Act does not call for diversity of backgrounds in the members. The Committee also observes that across the world, a perspective has gained ground that self-regulation alone does not work because medical associations have fiercely protected their turf and any group consisting entirely of members from the same profession is unlikely to promote and protect public interest over and above their own self-interest and therefore check-and-balance mechanisms are required. Besides, in today’s dynamic world, inputs from people with excellence and competence in other disciplines are also needed to add value to the working of an oversight body. It is for these reasons that in most countries such as the UK, Australia, etc. regulators are drawn from diverse groups. 

3.21 Keeping all these factors in mind and considering the fact that checks and balances in the MCI are not underpinned on sturdy systems and procedures, theCommittee is of the considered view that the composition of the MCI is opaque and skewed and diversity needs to be brought into this because having only medical doctors in the Council is not an enabling factor for ensuring reforms in medical education and practice. The Committee is convinced that if the medical regulator has to perform all its mandated functions in full measure and ensure that education in health disciplines fulfils its social mandate, it needs a vibrant framework with the right kind of capacity which can be achieved only by opening Council membership to diverse stakeholders such as public health experts and social scientists, health economists, health NGOs with an established reputation legal experts, quality assurance experts, patient advocacy groups, to name but a few. Such diversity and transparency will have the added advantage of reducing the monopoly of doctors in the MCI, thereby reducing the scope of cronyism and corruption. The Committee, therefore, recommends that urgent measures be taken to restructure the composition of MCI on the lines suggested above.

Comment

It is a known fact that there are lot of registered medical graduates who are eminent public health experts, medico-social activists , health economists. Many doctors are working with health NGOs with an established reputation for legal matters. Doctors are good quality assurance experts, work as patient advisory groups, so one do not have to go beyond the medical professionals to search for such talents. Law council consists of only lawyers and not lay persons. Similarly all established professional council are composed of representatives from same professional group

Observation 

3.23 During the examination of the Indian Medical Council (Amendment) Bill, 2006, and the Indian Medical Council (Amendment) Bill, 2013, the Committee had examined this issue but not favoured it on grounds that such sweeping powers might hamper the MCI in its day-to-day working and would subject the MCI to interference and pressure from the Central Government. 

3.24 The Committee has examined the issue afresh and given serious thought to the desirability of empowering the Central Government to issue directions to the regulatory body on matters of policy. The Committee notes that though all powers of approval/disapproval as per the MCI Act 1956 rest with the Central Government and all permissions are issues in its name, yet the Central Government has no power to disagree with the MCI. After comprehensive consideration, the Committeeobserves that the Government is the most important stakeholder in shaping health system in all its dimensions and attending to a range of reforms in medical education and practice. To push its policy and vision of health, the Government is, therefore, entitled to give directives to the MCI on policy matters of national importance. TheCommittee, therefore, recommends that the Government should have the power to give policy directives to the regulatory body. However, what exactly would be policy matters should be clearly and unambiguously defined so that such directives do not impinge on the functioning of MCI or violate its academic autonomy and any possibility of its misuse is obviated. The directive itself should be in the form of a ‘speaking order’ giving background and reasons and that should be made public immediately on issue. 

Comment

The PSC recommendation to empower the govt to give policy directions to MCI already exists and it can be reinforced

Observation

5.9 The Committee is concerned to learn from the experts and other stakeholders that the medical graduates emerging out of the medical colleges in the country, lack confidence and skills in performing basic healthcare tasks and even basic skills like conducting a normal delivery, providing early care for a fracture or suturing a wound are not within the competency of a graduate doctor. Realising this deficiency, graduate doctors seek post- graduate qualifications in order to acquire clinical expertise. Since, as against the approximately 55000 UG seats, there are only 25,000 PG seats as of now, a large number of graduate doctors do not get into PG and become redundant second class citizens because they are neither competent to practice independently nor do they have the social status. 

5.10 The Committee also takes note of the fact that one of the critical gaps in the system is the separation between the medical education system and the health system. The primary reason behind this separation is that our medical graduates work and train in tertiary care settings. Since the vast majority of patients seek healthcare services in small clinics and out-patient departments of small hospitals and a small proportion visits and an even smaller number are admitted to tertiary care institutions, which often deal with exotic and rare diseases, the graduate doctors are not exposed to primary and secondary health care conditions which is crucial to learn about common health problems in the country. Due to this skew in training, the graduate doctors are not equipped to manage common diseases and illnesses in the population. The MCI has failed to address this separation between the medical education system and the health system in the country. The Committee feels that the medical education that is imparted to a graduate doctor is only for basic treatment and if he is not competent enough to do even that, there is basic problem in the system which needs to be addressed. 

5.11 The Committee also observes that the most important flaw in the oversight of undergraduate medical education by the MCI is that the “maintenance of quality is assessed only in terms of fulfilling physical/ infrastructural requirements and there is simply no overall evaluation of the standard of medical education. Ironically, “maintenance of uniform standard of medical education” is the first objective of the MCI, as stated in the IMC Act, 1956. There is also no effort to assess the method of teaching/ learning, the evaluation process, the learning outcomes etc. The curriculum is still didactic. The world has moved to competency-based curriculum long back and we are still having workshops to decide whether we should switch- over to it or not. 

5.12 Considering all these facts, the Committee is constrained to observe that the existing system of the graduate medical education in the country has failed us and unless total revamping of the undergraduate education system is undertaken, the present system will not be able to generate the medical manpower required to deliver the ambitious programme of Universal Health Coverage. The Committee, therefore, recommends complete restructuring of the undergraduate education. The emphasis should be shifted to learning outcomes based on a curriculum that will train a holistic doctor with the requisite skills. The training of MBBS doctors should also be in primary care centres and secondary hospitals including district level hospitals. The curriculum should be designed keeping in mind the disease profile of the country and the gaps in the present system. The Committee simultaneously observes that India is a fast developing country and needs health services across a wide spectrum- from the basic diarrhoea treatment to the best tertiary care in the world. The country therefore, needs to have doctors who are competent and trained to provide health care services across this whole spectrum. It should therefore be ensured that the graduate doctor produced by the system is a competent basic doctor who also has the background to specialise. The Committee is convinced that unless these fundamental changes are carried out in the undergraduate medical education, India will not be able to meet the health challenges of the 21st century. 

 

5.13 The Committee takes note of the submission that today’s graduate doctor after doing his internship is not confident of practicing because his entire period of one year internship goes into studying for the PG entrance exam. The Committee observes that skill training which is very important for a medical professional, is not being acquired in internship. The Committee, therefore, recommends that the PG entrance exam should be held immediately after the final MBBS examination so that the graduate doctor could concentrate on practical skills during his internship. 

5.14 The Committee also observes that the medical education in India is increasingly depersonalised and has failed to instil humane values of care, concern, courtesy and compassion. The Committee feels that young doctors should not only have practical skills but also a lot of soft skills. The Committee, therefore, recommends that soft skills (including ethics) should be made one of the cornerstones of the syllabus of medical education. 

Comment

The observations  of PSC are correct but no solution has been offered. The syllabi and curriculum for UGs has to be revised at least once in 5 years. Although this process is taking place by the academic committee of MCI, the lack of timely approval by MoHFW makes it difficult to implement. So at  least in the matter of revision of syllabi and curriculum full autonomy should be  given to MCI so that timely revision takes place. 

Unless the  govt health policy empowers MBBS doctors and gives them  a specific role in health delivery, every MBBS graduate will aspire for PG admission and waste at least 4 or 5 productive years in preparing for MCQs. Only by re-establishing a 3 -tier or 4 -tier system of health delivery where every person has to approach a basic MBBS graduate before seeing a specialist, can the MBBS dr settle down for general practise in rural areas. This will also make health care cheaper and accessible. Rather than University obtained PGs in medicine , the stream of national board of examination should be given more importance and promoted so that opportunities for PGs become much more available and the academic resources  in the private sector can be fully tapped. 

5.26 The Committee notes that though the MCI has sent its recommendations for a unitary Common Entrance Test for admission to MBBS and PG courses long back, the Government is still grappling with sorting out issues for the implementation of the unitary Common Minimum Test. In the absence of a streamlined and transparent process of admissions, private medical colleges/ universities have developed their own screening and admission procedures which are primarily monetary based. It is public knowledge that the majority of seats in private medical colleges are allotted for a capitation fee going upto Rs. 50 lakh and even more in some colleges despite the fact that the capitation is not legal. This capitation fee is exclusive of the yearly tuition fee and other expenses. The Committee observes that the issue is not just about capitation fee. This has serious implications for our whole system of medical education and healthcare. One clear implication of this skewed process of admissions by way of sale of seats is that there may be a large number of students entering the system, who may not be upto the required standards. On the other hand, this system is keeping out the most meritorious but underprivileged students who can neither pay for seats, nor the high annual fee in private medical colleges. If a unitary Common Entrance Exam is introduced, the capitation fee will be tackled in a huge way; there will be transparency in the system; students will not be burdened with multiple tests; and quality will get a big push. TheCommittee, therefore, recommends that the Government should move swiftly towards removing all the possible roadblocks to the Common Medical Entrance Test (CMET) including legal issues and immediately introduce the same to ensure that merit and not the ability to pay becomes the criterion for admission to medical colleges. TheCommittee also recommends that introduction of CMET should be done across the nation barring those States who wish to remain outside the ambit of the CMET. However, if any such States wish to join the CMET later, there should be a provision to join it. 

Comment: The proposed all indian common entrance(CMET) itself is weighed more towards affluent and city based students. Although conceptually CMET can ensure uniform standard of the med graduates, as a pre-requisite different streams leading onto plus two like ICSE, CBSE, Pre-degree etc should be made into one common syllabi or curriculum. Even if the central govt come out with a CMET, the option to opt out of CMET exists because of the autonomy of the state govt which only by a central govt legislation can be solved and MCI don't have any role in it. To solve the issue of the capitation fee, which is illegal, even state govts have constituted various committees, e.g.. James committee in Kerala. Inspite of its strong recommendations against capitation fee (not the fee which private medical college can legitimately charge) it is an open fact that capitation fee is being collected by various private medical colleges. Only by a vigilant pro-active public, pro-active judiciary and stakeholders that this can be solved. There are instances at least in Kerala the aspiring students have brought out such illegal activities to the media. The judiciary should suo-moto take cases in such cases. Inspite of new legislations, such things can happen unless the stakeholders public and judiciary are vigilant

5.34 The Committee takes note of the fact that the MCI’s assessment of medical colleges is limited to ensuring rigid conformation to infrastructural and faculty norms and an inspection of the five year examination of new medical colleges. The MCI is not involved in any standardized summative evaluation of the final product- the medical graduate-coming out of new or old medical colleges. The final evaluation, and therefore, the final quality of every medical student, is left entirely to the medical colleges/ universities to assess. The Committee is, therefore, of the considered view that an entrance test alone will not do justice to the entire process and there is an urgent need to introduce a common exit test for MBBS doctors, which will go a long way in standardizing the passing out medical graduates and certify the competencies which are expected to be generated out of him. The Committee accordingly, recommends that urgent action be initiated to introduce a common exit test for MBBS doctors as an instrument of quality assurance and to ensure that the qualities and competencies of a doctor before he starts practicing are guaranteed and standardized in terms of various quality norms. 

Comment: Exit test is not a solution for ensuring uniform standard of passing out MBBS graduates. The institution of an accreditation committee as is in-vogue with AICTE and NAAC to ensure uniform standards in medical education is required. Another obvious contradiction that is in existence in health delivery system is, the govt insists on uniform standard for passing out MBBS Graduates , at the same time the govt also is planning to empower quacks and AYUSH doctors to practice modern medicine. So these MBBS doctors after going through a rigorous course and curriculum are compelled to appear for an exit test while those who are illegally practising modern medicine including quacks and AYUSH doctors  are given permission to practise modern medicine. What will be the fate of MBBS doctors who pass out and who fail in exit test? Will they be barred from practising, while quacks are allowed to practice modern medicine even without degree. This contradiction has to be addressed before suggesting exit test

5.36 The Committee observes that though the constitutionally designated fee regulation committee of the respective State Government fixes the fee to be charged by private medical colleges, yet the yearly tuition fee and other expenses that have to be paid thorough a year duration work out in the range of Rs. 12-13 lakh or even more which is certainly exorbitant and beyond the paying capacity of poor but meritorious students and the same, therefore, needs to be rationalized. As of now, the Union Health Ministry does not play any role in fixation of the tuition fee. The Committee is of the opinion that since the Ministry of Health and Family Welfare plays a critical role in supporting the regulation of medical education, it should be enabled to play a role in regulating fee structure in private medical colleges so that the right quantum of tuition fees to be charged by private medical colleges is ensured and there is uniformity in fees across the country amongst the public and private sector medical colleges/institutions. The fee structure should be strictly be enforced and action should be taken against erring managements. 

Comment: This view point is fully acceptable at the same time a committee should go into the financial feasibility of medical colleges and per-head cost to train a medical graduate for financial survival of medical colleges if there is need for financial grants the concept of aided medical colleges in the private sector also has to be considered, e.g there already exists many homoeopathy and Ayurveda medical colleges which are receiving grant-in-aids from government; then why cant governments support private medical colleges and reduce the cost on students. 

The model existing in US may be examined wherein the Govt extends support in terms of scholarships to partially cover the tuition fees of medical graduates

6.8 The Committee is concerned to note that the approval for PG seats is based on rigid criteria for teachers, teaching beds, patient attendance & infrastructure and there is no mechanism in place to evaluate the PG trainees for their skill and competence prior to their certification as a designated specialist. The present MCI system of oversight of PG medical education does not at any stage evaluate the teaching and learning process or have any benchmarks for quality. Instead of devoting its attention to addressing the issue of quality and competence which has a direct bearing on the safety of patients seeking treatment, the MCI is obsessed with enforcing rigid regulations that stifle improvement and innovation. The Committee takes note of the information made available to it that in the USA there are different specialty Boards to monitor and certify training, while the MCI has a single nine-member Post Graduate Medical Education Committee to prescribe standards of Post Graduate Medical education. The Committeefinds it inconceivable that a single nine-member Post Graduate Committee has the breadth of expertise to provide guidelines, let alone set standards, to span multiple specialty disciplines. The Committee is, therefore, convinced that an overhaul of the whole system is required, and accordingly, recommends that the PG medical education system should be restructured in such a way that training is assessed by the quality of the product and not by the infrastructure and a robust system be put in place for evaluation of skills and competencies. The Committee also observes that there is a need to separate regulation of graduate and post-graduate medical education as these two phases of medical education need different kind of expertise. The Committee, therefore, concurs with the suggestion that there should be separate UG and PG Boards for the regulation of UG and PG medical education. 

6.9 The Committee also recommends that post-graduate education should be governed by a body like NBE, integrating the two systems of PG medical education that currently exist and function through a well-coordinated array of specialty sub-boards which define desired competencies and set standards for each major discipline. 

Comment: The proposals are acceptable. But the system suggested to monitor practical experience and competency required for a specialist may not be practicable. The whole post graduate education can be brought under National Board of Examinations which is fairly doing commendable job. When the PG education is transferred to NBE, the medical colleges can concentrate more on under-graduate education. The NBE is effectively using the talents in the private sector which is phenomenally present in the country. The post graduation is only a registration to practise a specialty. In UK and other countries even after post graduation five years has to be spend under a consultant before a specialist becomes an independent consultant. Feasibility of this system may be explored

6.12 The Committee has already commented on the need for a Common Entrance and Exit Test for UG medical education in the previous Chapter. The Committee is of the view that the grounds which mandate introduction of common Entrance and Exit examinations for UG medical education are also valid for PG education. Post Graduate seats are in great demand. The Committee has been given to understand that in the absence of a transparent and streamlined process of admission, PG seats are sold from Rs. 1 crore to Rs. 1.50 crore per seat. The Committee has already dwelt on the issue of capitation fee and its ill-effect. The Committee would, therefore, refrain from repeating those details. Keeping all these factors in mind, the Committee recommends that the Government in consultation with the MCI should swiftly move towards introducing a common entry test for admission to post-graduate and super-specialties also. The Committee also recommends the introduction of a common exist test for the passing out Post- Graduates to certify and standardize their competencies. 

Comments: The comments already expressed for UG are also applicable to PG education. 

6.18 The Committee agrees with the suggestion that there is an imperative need to promote PG degree in Family Medicine because Family Medicine combines a broad set of clinical competencies and therefore Family Physicians are more equipped to manage most of medical problems encountered at primary level. The Committee recommends that the Government of India in coordination with State Governments should establish robust PG Programmes in Family Medicine and facilitate introducing Family Medicine discipline in all medical colleges. This will not only minimize the need for frequent referrals to specialist and decrease the load on tertiary care, but also provide continuous health care for the individuals and families. 

Comments: Suggestion fully acceptable. Along with introduction of family medicine discipline, the three-tier system of health care has to be strictly introduced whereby MBBS doctors or post graduates in family medicine will be the first contact health care personal. Ninety percent of ailments can be managed at this level itself. Specialists hospitals - both govt and private can effectively utilise their resources for secondary and tertiary care 

6.21 The Committee observes that India is a country of 1.24 billion that will reach 1.7 billion by the middle of the century. Therefore, only 24000+ PG seats are unquestionably much less than national needs. It is, therefore, critical for the country to augment the production of specialists both as a development imperative and a pathway for ensuring quality universal health care to the masses. Within the existing framework, it will not be possible to expand rapidly beyond the present strength. The Committee, therefore, recommends that the existing norms governing the allotment of number of PG seats to an Institute on the basis of the bed strength and number of PG teachers be rationalized and all the clinical facilities (both public and private) be utilized to impart training so that the production of PG doctors is scaled up. The Committee has also noted that the recent increase in PG seats has been indiscriminate and in future we may have a lot of Post Graduate doctors who may not be competent in the specialty in which they claim to be specialized. The Committee recommends that the increase in PG seats should not be indiscriminate and great caution should be exercised on maintaining quality of training and certification. The Committee also observes that while the increase in PG seats will produce more specialists and also help to provide required faculty for medical colleges, it may result in fewer graduate doctors opting for primary health care. The Committee, therefore, recommends that the framework of Post Graduate Education be designed in such a way that it remains aligned with principles of universal health care. 

Comment: Acceptable

6.23 The Committee observes that though research is a mandate of post- graduate training and evaluation in both MCI and NBE PG Programmes, seventy years of having a thesis as part of the PG programme has done nothing to produce nationally relevant data for the management of the diseases prevalent in the country or to establish robust research enterprise within the medical colleges and institutions. The absence of clinical research on common problems prevalent in the country and the resultant lack of local information has created a disconnect between official statistics and the problems on the ground. The Committee, therefore, recommends that the component of research thesis as part the PG programme needs to be holistically restructured in such a way that post-graduate students are guided to conduct research relevant to national health program priorities and generate nationally representative data periodically. 

6.24 The Committee also recommends that the Indian Council of Medical Research should guide such studies by linking with student researchers and faculty guides, from select institutions across India. 

Comment: Acceptable. To implement such a program just like UGC there should be a medical grants commission has to be set up and proper funding should be ensured for the research 

7.15 The Committee takes note of the fact that there is acute shortage of teaching faculty which not only entails adverse impact on the quality of medical education but is also a barrier to the establishment of new medical colleges. The MCI's policies are largely responsible for this state of affairs, because very rigid norms have been provided in the "Regulations on the Teachers Eligibility Qualifications 1998" and only full-time teachers are acceptable to the MCI. It does not recognize qualified specialists in district hospitals, reputed private and public sector hospitals not attached to medical colleges and non-medical public health specialists as capable of teaching in a medical college on a part time basis. The MCI also does not allow for sharing of faculty across government medical colleges in a state, through Information Technology enabled "common classrooms". It also does not permit surgeons to teach anatomy and physicians to teach physiology part time, though their understanding of these basic disciplines is very clinically relevant. 

7.16 The Committee is constrained to observe that had the MCI been able to unleash reforms of far-reaching impact to tide over faculty shortages, these barriers would have been removed to a large extent. The Committee therefore, recommends that keeping in mind that the country has a huge pool of talented doctors in both public and private sector hospitals, the MCI should look outside this rigid teaching faculty definition and find out-of-the- box solutions to tap the pool of practicing doctors who are interested in teaching as adjunct or part time teaching faculty. Of course, this should be done with some defined parameters and till a certain percentage only. 

7.17 The Committee would also like the Government to have a re-look at the retirement policy of teachers and work out a re-employment policy. The Committee does not see any reason why a retired specialist at the age of 60 cannot be re-employed as a teaching faculty on a full time or part time basis. 

7.18 The Committee takes note of the submission made by the President of MCI that "If the Honorary system is there, all these experienced people can come in. We must utilize whatever workforce, experienced or trained or a degree holder is available" and expects that the words of the MCI President would be matched with the action on the ground. The Committee recommends that early action may be taken in this regard. 

7.19 The Committee observes that the norms and standards as stipulated in the Regulations on the "Teachers Eligibility Qualifications 1998" had been fixed at a time when Information Communication Technology Tools were not so advanced. Despite tremendous advancement in IC Technologies and the advantage of our IT strength, ICT tools, virtual classrooms, and e- learning have not been incorporated in the medical curriculum in tune with the modern times. It is true that there are certain practical skills which have to be learnt bedside in a teaching hospital or a district hospital. But classroom teaching can be shared substantially with IT connectivity. The Committee therefore recommends that immediate action needs to be initiated to allow for sharing of faculty across government medical colleges in a state, through information technology enabled common classrooms. Subsequently, this facility may be extended to private medical colleges also, with check-and-balance mechanisms. The Committee is of the considered view that this measure will not only go a long way in making up for faculty shortages, but also take care of the current practice of engaging of ghost faculty by private medical colleges. 

7.20 The Committee also recommends that the ambit of the Regulation by virtue of which the clinical experience of the specialists in the ESIC hospitals were equated with the teaching experience for the purpose of adopting them into teaching cadre, should be extended to other Government Hospitals also so that the CMOs and other experienced doctors who have worked in the Government Hospitals for long and have experience of dealing with thousands of patients can come into the teaching faculty. 

7.21 The Committee takes serious note of the fact that the MCI has continued to oppose the induction of specialists who have passed the nationally standardized DNB examinations conducted by the National Board of Examinations and declared that they cannot become teaching faculty in medical colleges, despite the Government of India and even courts declaring the equivalence of post-graduate degree awarded through MCI certified and NBE certified Programmes. Since lack of teaching faculty is the main impediment in expanding and opening more medical colleges, there is an imperative need to utilize all available expertise to augment the required pool of teaching faculty. The Committee in the earlier part of this Report, has recommended the merger of the DNB with MD Programmes. But till then, DNB certificate holders may be utilized in teaching faculty provided they have at least two years of teaching experience. 

7.22 The Committee takes note that the assessment of the cumulative shortfall of teaching faculty for the undergraduate and post-graduate courses is underway. TheCommittee recommends that the assessment be expedited so that the database so generated could be utilized for Human Resource planning and forecasting. 

Comment: The utilisation of consultants in the private sector as teaching faculty, introduction of Honorary Professorship,Part time professorship IT enabled common class rooms, virtual class rooms, utilising clinicians to teach basic sciences are all welcome steps

10.17 The Committee agrees with the need for mandatory recertification and Continuing Medical Education and a structured programme of periodical update of the knowledge of doctors as quality assurance mechanisms and observes that the MCI (or any other body) in consultation with the Ministry of Health and Family Welfare should take the responsibility in this regard. The Committee observes that in the absence of a structured mechanism for recertification and Continuing Medical Education, pharma companies are filling the gap due to which doctors are dependent on them for the update of their knowledge. This influences them in their professional practice. The Committee, therefore, recommends that the renewal of registration and Continuing Medical Education be made mandatory so that the health system's requirements get strengthened and doctors practice more appropriate and rational technology instead of picking up the technologies pushed by the interested agencies. 

Comment: Once a MBBS doctor or a post graduate leaves the alma-mater there is no structured mechanism by the govt to update their knowledge. Indian Medical Association is the only body which suo- moto has taken this responsibility and is conducting monthly CME programs through its 1700 plus branches at local level apart from those done by its academic wings. It is squarely the responsibility of the govt  to see that doctors are updated in their knowledge. While insisting on re-registration a mechanism for upgradation of knowledge of  MBBS doctors and Post graduates should be ensured. A fund has to be created by the govt for this purpose which could be disbursed to IMA and other professional bodies for conducting CMEs

11.5 The Committee notes with serious concern that medicine is no longer a priority for the brightest among the youth and the disinterest of our brightest to opt for teaching jobs in public sector health institutions is increasing due to various factors, one of which is certainly inadequate remuneration packages. The Committee observes that the whole medical education system will collapse if there are not good teachers for our medical colleges. Let us also not forget that today’s medical student is tomorrow’s physician and no society can afford to leave healthcare in the hands of mediocre doctors. All these facts warrant that measures to attract good talent towards medical profession and retain them, by way of offering attractive remuneration packages are required to be immediately initiated. The Committee fully endorses the view that medical profession demands much higher commitment, knowledge, skills, competence and accountability and doctors have to work under very trying conditions. It is, therefore, imperative that the pay structure of doctors and faculty should be so designed as to provide compensation to medical fraternity commensurate to their years of training and research. 

Comments: This point is fully and strongly accepted. Although doctors should have the highest commitment, knowledge, skills and competence it is equally important that medical profession is chosen not by the brightest but by those who have inclination and compassion towards patients. Medicine is both a science and an art. So commitment and compassion to the patient is equally important as their knowledge and skill. If medicine is practised as an art and science, the problem of alienation of the medical fraternity from the public does not arise. The entrance examination system in existence only assess the competence of an aspirant not his inclination commitment and aptitude towards the profession to that extend the entrance examination system should be modified rather than trying to address the problems of ethics and hostility later on. What medical profession needs is a person of average intelligence but with full commitment compassion and aptitude towards healing

Regards,

Prof Dr A Marthanda Pillai

Immediate Past National President of IMA


The following is the final part of the critical review of the Key observations of the committee 

5.26 The Committee notes that though the MCI has sent its recommendations for a unitary Common Entrance Test for admission to MBBS and PG courses long back, the Government is still grappling with sorting out issues for the implementation of the unitary Common Minimum Test. In the absence of a streamlined and transparent process of admissions, private medical colleges/ universities have developed their own screening and admission procedures which are primarily monetary based. It is public knowledge that the majority of seats in private medical colleges are allotted for a capitation fee going upto Rs. 50 lakh and even more in some colleges despite the fact that the capitation is not legal. This capitation fee is exclusive of the yearly tuition fee and other expenses. The Committee observes that the issue is not just about capitation fee. This has serious implications for our whole system of medical education and healthcare. One clear implication of this skewed process of admissions by way of sale of seats is that there may be a large number of students entering the system, who may not be upto the required standards. On the other hand, this system is keeping out the most meritorious but underprivileged students who can neither pay for seats, nor the high annual fee in private medical colleges. If a unitary Common Entrance Exam is introduced, the capitation fee will be tackled in a huge way; there will be transparency in the system; students will not be burdened with multiple tests; and quality will get a big push. The Committee, therefore, recommends that the Government should move swiftly towards removing all the possible roadblocks to the Common Medical Entrance Test (CMET) including legal issues and immediately introduce the same to ensure that merit and not the ability to pay becomes the criterion for admission to medical colleges. The Committee also recommends that introduction of CMET should be done across the nation barring those States who wish to remain outside the ambit of the CMET. However, if any such States wish to join the CMET later, there should be a provision to join it. 

Comment: The proposed all indian common entrance(CMET) itself is weighed more towards affluent and city based students. Although conceptually CMET can ensure uniform standard of the med graduates, as a pre-requisite different streams leading onto plus two like ICSE, CBSE, Pre-degree etc should be made into one common syllabi or curriculum. Even if the central govt come out with a CMET, the option to opt out of CMET exists because of the autonomy of the state govt which only by a central govt legislation can be solved and MCI don't have any role in it. To solve the issue of the capitation fee, which is illegal, even state govts have constituted various committees, e.g.. James committee in Kerala. Inspite of its strong recommendations against capitation fee (not the fee which private medical college can legitimately charge) it is an open fact that capitation fee is being collected by various private medical colleges. Only by a vigilant pro-active public, pro-active judiciary and stakeholders that this can be solved. There are instances at least in Kerala the aspiring students have brought out such illegal activities to the media. The judiciary should suo-moto take cases in such cases. Inspite of new legislations, such things can happen unless the stakeholders public and judiciary are vigilant

5.34 The Committee takes note of the fact that the MCI’s assessment of medical colleges is limited to ensuring rigid conformation to infrastructural and faculty norms and an inspection of the five year examination of new medical colleges. The MCI is not involved in any standardized summative evaluation of the final product- the medical graduate-coming out of new or old medical colleges. The final evaluation, and therefore, the final quality of every medical student, is left entirely to the medical colleges/ universities to assess. The Committee is, therefore, of the considered view that an entrance test alone will not do justice to the entire process and there is an urgent need to introduce a common exit test for MBBS doctors, which will go a long way in standardizing the passing out medical graduates and certify the competencies which are expected to be generated out of him. The Committee accordingly, recommends that urgent action be initiated to introduce a common exit test for MBBS doctors as an instrument of quality assurance and to ensure that the qualities and competencies of a doctor before he starts practicing are guaranteed and standardized in terms of various quality norms. 

Comment: Exit test is not a solution for ensuring uniform standard of passing out MBBS graduates. The institution of an accreditation committee as is in-vogue with AICTE and NAAC to ensure uniform standards in medical education is required. Another obvious contradiction that is in existence in health delivery system is, the govt insists on uniform standard for passing out MBBS Graduates , at the same time the govt also is planning to empower quacks and AYUSH doctors to practice modern medicine. So these MBBS doctors after going through a rigorous course and curriculum are compelled to appear for an exit test while those who are illegally practising mode