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Privileging primary care -George Thomas & C Rammanohar Reddy
-The Hindu

The National Medical Commission Bill’s proposal to permit ‘for profit’ colleges will undermine the aim of creating a cadre of medical professionals able and willing to work in small towns and villages

The many reports commissioned by the Government of India on the state of medical care invariably highlight one fact: a large number of Indians do not have access to proper and adequate medical care.

India currently faces a “double whammy” of having to deal with a substantial burden of both infectious and chronic diseases, and of medical professionals being concentrated in urban areas. Dealing with these two sets of challenges requires action on many fronts. Educating a cadre of medical professionals willing and able to deal with these issues is one important set of actions that is required. But using medical education as the sole, or even the primary, tool for dealing with India’s health challenges is to use a blunt weapon which is unlikely to effectively address these concerns.

Problem with draft Bill

Fundamentally this seems to be the major problem with the draft National Medical Commission Bill that the Niti Aayog has prepared, which, if approved, will set up a new body that will replace the Medical Council of India (MCI). It is true that the MCI is “ossified and opaque”. It has failed to provide a leadership role in educating a cadre of medical professionals that is trained and willing to deal with the medical problems of the people of India, and, sadly, it has become associated with large-scale corruption in granting approvals for establishing medical colleges.

While creating a new structure to replace the MCI, it would be visionary to utilise the opportunity to create a new framework to train a cadre of medical professionals equipped to deal with the needs of the people.

Another major recommendation of the committee is to permit “for profit” entities to establish medical colleges. The rationale given is that (a) micromanagement as practised today in the approval of new medical colleges by the MCI encourages rent-seeking behaviour, (b) a cap on fees in private colleges discourages their entry and thereby undermines the objective of a rapid expansion of medical education, and (c) enforcing regulation on fees is difficult.

Apart from the extremely disturbing indirect admission that the government is unable to enforce the rule of law, and that underground financial dealings are commonplace in higher education with the government being a helpless spectator, this recommendation to permit “for profit” colleges will severely damage the stated objective of providing a cadre of medical professionals able and willing to work in small towns and villages.

Realising this objective is best served by making it clear that the career path for most doctors will have to be as primary care physicians, not just in cities but also in small towns and villages. Efforts must be made to make the career of a primary care physician attractive. In most urban areas of India, we have too many specialists who are dependent for their income on a small pool of paying patients. It has led to many unethical practices, the most common being of doctors collecting a kickback for referring a patient, and for investigations. Private colleges which charge huge amounts for medical education exacerbate this unhappy situation by producing a group of doctors who begin their careers under pressure to earn very high incomes so that they can recover the cost of expensive medical education. The overall deleterious effect on society is incalculable. The present system also formalises a system of medical education in which there are two distinct layers of students, divided by privilege. This is undesirable in any field, but more so in medicine, where empathy, altruism and high ideals are greatly prized by the general public and should be encouraged.

At present, the role model of aspiring medical students is the emergency care physician and surgeons performing highly complex surgeries. The reality on the ground is that most lives are saved and most pain is alleviated by the primary care physician. Throughout the developed world, there is a great emphasis on primary care doctors, and most medical graduates enter primary care. But this is not so in India, and needs to change.

We need to make primary care the first option of most medical graduates in India as well. We need to ensure that medical aspirants know as much as possible what their working lives are going to be like. It will help ensure that only those with an outlook in tune with the requirements of medical professionals enter medical colleges.

Shortage of teachers

A rapid expansion of medical colleges is simply unattainable. More than any other limitation, it is the severe shortage of suitably qualified teachers in certain absolutely essential specialties (for example, in forensic science, community medicine, tuberculosis and radio diagnosis) that is the curbing factor. This sorry pass has come about due to years of failure to take any steps to deal with this obvious problem and for this the blame has to be placed on the MCI which failed to provide leadership and guidance on this faculty shortage. It will take some years to train enough teachers.

Therefore, no more medical colleges should be opened till sufficient faculty are available. Private colleges merely poach faculty from government colleges and surely that cannot be considered a solution.

On the MCI itself, the report of the Niti Aayog committee which drafted the bill has concluded that the best way to deal with the problem is to replace the elected body by one with only nominated members, who would be selected mainly by the Central government and a few by the State governments. The committee has also recommended that the proposed National Medical Commission should have only 20 members, with a full-time chairperson and secretary.

With the MCI now an unwieldy body comprising more than 100 members, this proposal is a good idea, but it would be sensible that at least a section of the membership of the commission should be elected. A mix of nominated and elected members will encourage a healthy tension between various points of view and is more likely to ensure thoughtful debate. Bodies with only nominated members tend to become narrow-minded with all members overly concerned with pleasing the government of the day and being unable or unwilling to speak truth to power.

There are a lot of good things in the draft bill. The recommendations to streamline the administrative functions, create four verticals to oversee undergraduate and postgraduate education, and establish a medical assessment and rating board as also a board for medical registration all have the potential to produce major positive changes.

The fundamental objective, however, should not be forgotten: creating a cadre of medical professionals trained and equipped to work effectively given the social conditions of the country. Opening the door to expensive private education is directly opposed to this objective.

George Thomas is an orthopedic surgeon and former Editor of the Indian Journal of Medical Ethics (email: george.s.thomas@gmail.com); C. Rammanohar Reddy is Readers’ Editor, Scroll.in. (email: crr100@gmail.com)