Understanding the National Medical Commission Bill 2017 (India) Part 1: Bridge Course

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):

2018-01-05 21_07_00-3202LS(E)-Prelim.Clause 49(3) and (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:

2018-01-05 22_06_10-3202LS(E)-Prelim.Clause 31(8)

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)

 

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6 thoughts on “Understanding the National Medical Commission Bill 2017 (India) Part 1: Bridge Course

  1. Sreejith T

    Sir, you do realize that the AYUSH has medicines of their own they claim to be effective in treatment. Why do the gov’t need them to prescribe modern medicine?

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    1. drroopesh Post author

      Dear Sreejith,

      I don’t know anything about Indian and Alternative systems of medicine, so will refrain from commenting on their effectiveness. However, it is an established fact that prescribing drugs without fully understanding how they act, etc. is fraught with danger.

      I do not claim that the government ‘needs’ them to prescribe modern medicine. Many of them are prescribing modern medicines already, without any directive/approval from the government. What I suspect, however, is that the government sees an opportunity to use them to fulfill a need of the people in general.

      Please understand that there is a demand for modern medicine that is unmet. Many of these practitioners are exploiting the situation, and prescribing modern medicines. Since this ground reality exists, (and the government is well aware of it), I suspect they merely want to tap into this pool of practitioners. Instead of letting them run loose and unregulated, the government hopes to streamline and regulate prescription practices. This should reduce the number of adverse outcomes due to unintended drug interactions, as well as irrational prescriptions.

      The moot point is: they are already there, and prescribing modern medicines without oversight. Formalizing such practice through introduction of a bridge course will at least reduce irrational prescription and permit some degree of regulation (considering those who have passed the bridge course will be listed in a separate National Register).

      I hope the above helps clarify things.

      Regards,
      Dr. Roopesh

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      1. Sreejith T

        Sir, if something illegal happens, how can legalizing it be the solution.? If there is lack of doctors, gov’t should work towards increasing medical colleges as well as seats. If it is made legal today, would it ever be possible to undo this in the future when there is adequate doctors available?
        The same gov’t that wants to test the standard of doctors by EXIT exam wants to allow such substandard practices.
        What an irony.
        When it comes to ground reality, would it matter whether they are listed in separate registry? Even when it’s illegal gov’t can’t control them and making it partially legal is only going to let them loose.
        Yes there is surely lack of evidence in effectiveness of majority of practices of Indian systems of medicine and especially homeopathy. As a member of medical community whose standard the gov’t wants to test, I have a problem with why the gov’t has no issue in promoting such pseudosciences.

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        1. drroopesh Post author

          Dear Sreejith,

          Will increasing the number of medical colleges or MBBS seats increase the number of MBBS graduates serving in rural areas? There has been a tremendous increase in both medical colleges as well as MBBS seats in the past 2 decades. Has that improved the status of healthcare in rural areas?

          It is alright to protest the legality, but the real issue that seems to be under consideration is not necessarily of legality, but of service provision.

          When it comes to ground reality, would it matter how many MBBS graduates are listed? Governments have failed to enforce rural service, and graduates have wilfully defied regulations requiring them to serve in rural areas. Surely, that, too, cannot be blamed elsewhere! I suspect we are merely giving excuses for our own selfishness and inadequacies.

          If there were adequate MBBS graduates actually serving in rural areas in the first place, and such graduates were competent to provide primary care, I doubt there would be much scope for AYUSH practitioners to prescribe modern medicines in those settings.

          If an AYUSH practitioner can compete with an MBBS graduate (and thrive), it only highlights the quality of the MBBS doctor. If the MBBS graduate is that good/superior, people should have no reason to patronize quacks or AYUSH practitioners who prescribe modern medicines. Similarly, if MBBS graduates are truly better than AYUSH practitioners, why should they feel threatened by the latter?

          Perhaps the AYUSH practitioners are merely soft targets, diverting attention from the real issues plaguing medical education and training in India?

          Regards,
          Dr. Roopesh

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      2. Jawed

        Dear Dr.
        This type of approval and government regulated bill is necessity of time ,I am a general public not a practitioner and thinking this bill is much important for general public .Because the MBBS doctors they don’t want to come in rural areas to paticipate their services .incase of emergency we have to move ayush privte practitioners that time such type of practitioners paying their attention ,and taking care for us.
        My vote is in favour of ayush practitioners ,and NMC bill should be passed in parlyament against MBBS .
        Jawed.

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        1. drroopesh Post author

          Dear Jawed,

          Thank you for reiterating what I have already stated in the article.

          I would like to point out that the NMC Bill is not directed ‘against’ MBBS graduates. Rather, it is intended to regulate all matters concerning training in modern scientific medicine.

          Regards,
          Dr. Roopesh

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