The National Medical Commission (NMC) Bill 2019 was passed by the Rajya Sabha last week and now awaits passage in the Lok Sabha, where it has been reintroduced with the changes based on recommendations of the Parliamentary Standing Committee on Health and Family Welfare, to which it had been earlier referred by the lower house.

While the Health Minister described the Bill as an achievement of the government that will enable greater access to quality medical education and highly trained professionals, the medical fraternity clearly does not seem to subscribe to that, as evident from the widespread dissent and protests by doctors against various provisions outlined in the bill.

What is the NMC Bill about?

The NMC Bill provides for the formation of a National Medical Commission (NMC) to replace the Medical Council of India (MCI). The authorities see this as a step in curtailing corruption that has plagued the MCI, leading to its disbandment. The state governments too are to constitute State Medical Councils within three years of the passing of the bill.

The NMC will have a strength of 25 members who are appointed by the Central government. A Medical Advisory Council will be formed to route the suggestions of the states to the NMC. The body will regulate policies regarding medical institutions, determine manpower and infrastructure requirements for healthcare in the country and determine the fees for 50% seats in the private and deemed universities that fall under their control. However, that is not the primary bone of contention here.

The Bill brings into existence a common National Exit Test (NEXT), that final year MBBS students across the country will be required to write in order to pursue the practice of medicine or obtain entry into postgraduate courses in medicine. This will be in addition to a common eligibility-cum-entrance test at the undergraduate level.

The Bill also allows for Community Health Providers at the mid-level to practise medicine in a manner limited to primary and preventive healthcare, and in some cases under the supervision of a registered medical practitioner.

So, what is worrying doctors?

The medical fraternity finds itself divided on various aspects of the bill with many senior professionals voicing their concern. What is significant is that many of the objections or points of concern that they raise affect not just the ‘practice’ of the profession, but also impinge directly or indirectly on citizens, either as patients or aspiring healthcare professionals.

The main opposition has been to Section 32, which allows grant of a licence to community health providers to practise medicine. The section was not part of the original bill that was referred for review to the parliamentary standing committee.

What this means effectively is that around 3.5 lakh persons without a medical degree will now be allowed to prescribe allopathic medicine at a primary and preventive level, upon satisfying the terms of the licence. This has raised concerns about the quality of healthcare for citizens and the threat of an increase in “quackery”.

Dr.Santanu Sen, National President, Indian Medical Association and Member of Parliament, spoke out against the provision: “ As per Clause 32, they are making medicine into a master of quackery course by allowing lab technicians, ECG technicians, X-ray technicians, compounders, ambulance drivers, who are directly or indirectly associated with the medical system, to get a licence. At least there is a provision that Ayush doctors will be trained, but in this case, anyone can become a doctor, anyone can be allowed to prescribe like a doctor.”

Dr. Vivek Kadambi, Medical Director, Belle Sante Institute of Functional Medicine, Bangalore, has some interesting insights in this matter. He points out that while the NMC bill provides for mid-level Community Health Providers (CHP) through a short course for paramedics and practitioners of Alternative Medicine, it is unclear on how, where and when the community workers can practice and prescribe. It clearly limits the numbers of licenced practitioners to one-third of the total qualified doctors in that region but is unclear on the geographic limits where CHPs would practice.

“Proponents of the NMC bill give examples of similar mid-level health practitioners successfully providing services worldwide, but they forget that these countries have a culture and regulatory bodies that can ensure effective implementation of rules and regulations,” said Dr. Vivek. “While the visionaries of the bill have a Utopian dream that the CHP will work in the government Peripheral Health Centers, what is more likely is that these CHPs will migrate to urban areas and enter mainstream private medical institutions, thus threatening to displace many qualified MBBS doctors from their jobs.”

Another perspective that has emerged on this contentious clause questions whether this will lead to the death of traditional medicine, and a dearth of practitioners of such medicine, as more AYUSH practitioners move to allopathy. Dr K K Agarwal of AIIMS, Delhi says: “Modern medicine or Allopathy is western medicine as the drugs used have been developed in the West. The West wants Ayurveda and Homeopathy to be finished in India. Allowing practitioners of AYUSH systems of medicine to practice modern medicine gives a wrong perception of their skills. The message that goes out is that AYUSH systems of medicine are not competent enough to treat common illnesses, which is incorrect and an insult to practitioners of AYUSH.”

Implications for medical education

Concerns have also been raised against the capping of the fee regulation to 50% of the seats in private and deemed universities against 85% earlier, which could lead to an increase in capitation fees in private colleges. Dr Vivek said that this provision has received a mixed reaction from members of the Indian Medical Association.

Dr Santanu, however, raised explicit objections to this provision, saying “As per Clause 10(i) of this Bill, not only will 50 per cent of the seats be sold freely but for the remaining 50 per cent too, this board will not prescribe the capitation fee. So indirectly, hundred percent seats of all private medical colleges will be open for sale. Can you believe after this that meritorious students from remote districts of the country will be able to even dream of becoming a doctor? This Bill will indirectly lead to the mushrooming of private medical colleges and nothing else.”

Students and aspirants have opposed NEXT as they feel that the weight given to a single exam will affect their chances at higher education and medical practice. Dr Sen also raised issues with the prescribed format of the test. “In the final year MBBS, in the practical examination, we answer advanced questions on medicine, surgery, gynaecology, etc. But if this NEXT exam is completely an MCQ (multiple choice questions) test, then you can run a distance course as well – Open a medical college, no hospital needed, and run a distance course.”

Central control

In addition to the above objections, protesting members of the medical fraternity expressed reservations about the composition of the NMC and the nomination process of its members. The concern that the body will be controlled by the centre is widespread.

Dr Vivek argues: “The fundamental logic behind the NMC bill with respect to governance appears to be flawed. The government’s view is that the MCI is a corrupt body and hence has to be replaced by a government-nominated body to regulate medical education based on the false assumption that government officials are never corrupt. Despite the IMA pointing out that the MCI members were always chosen through a democratic process of election, the NMC bill seems to advocate a selection and nomination process as a process superior to any democratic election process.”

The past few weeks have seen considerable tumult over the issue, and while latest reports indicate the withdrawal of strike by doctors, the medical fraternity and the central government are yet to see eye to eye on many issues that need resolution. Till that happens, citizens too will have to watch out for what the future of medical education and treatment in this country may hold for them.

[With inputs from T R Gopalakrishnan, Consulting Editor at Citizen Matters]