The National Medical Commission Act, 2019 has divided India’s medical fraternity, with some vehemently opposing it and others listing its many benefits.
Its proponents say the Act can reform other areas of professional education too, while its detractors believe that certain provisions “subjugate federalism at multiple levels”.
The National Medical Commission Act (NMC), which replaces the Medical Council Act, demands a better understanding.
We address three provisions of the Act that have invited maximum criticism. These are also the factors that can have a direct impact on other professional education domains if the NMC model of reforms is applied to them.
Setting standards through National Exit Test
The NMC Act proposes a common National Exit Test (NEXT) for all final-year MBBS students. Only after clearing NEXT will the students get the licence to practise medicine and admission in postgraduate courses. Opponents argue that it does away with the checks and balances at multiple levels, clubs different exams together, and may exert undue pressure on the students.
The pressure of the exit exam is not undue because as doctors they will be expected to make life and death decisions. Students anyway face board and entrance exams and are prepared to deal with such pressure.
It is commonly believed that private colleges care little about academic standards as long as students have the ability to pay the fees. The ‘management seats’ offered on the basis of capitation fee allow entry to students who have failed to clear the eligibility criteria.
By setting high quality standards for exit, NEXT will perform two functions simultaneously: attract the right kind of students to the medical profession, and produce more competent doctors. Students who get a seat just because they could afford the capitation fee are less likely to clear the NEXT.
Over time, there will be fewer instances of such students trying to enter the profession. This will automatically help build a pipeline of more competent doctors.
Shifting focus to learning outcomes
NEXT can help build a uniform benchmark against which the performance of private medical colleges can be assessed. Although the criteria for rating and assessing private medical colleges is yet to be decided, linking it to the performance of students in the exit exam could shift the focus from infrastructure requirements to learning outcomes. In order to boost their ranking and enrolment, private institutes would now be motivated to invest in quality education and ensure that a majority of their students perform well in the exit exam.
According to the NITI Aayog, input-based regulation in medical education has increased entry barriers, created an inspector raj, and failed to incentivise quality in medical education. The NMC Act attempts to correct this. New medical colleges are no longer required to annually renew their permission before recognition, which does away with the need for annual inspection.
This will reduce artificial entry barriers (based on parametres other than the quality of education), and bring a renewed focus on learning outcomes. Rather than deregulating and giving private colleges a free rein, the new Act only changes the nature of regulation to ensure that only the best performers survive.
Regulating 50% seats checks profiteering
The Act permits the government to regulate fees for only up to 50 per cent of the seats in private colleges, a matter of grave concern for many. This, however, can be seen as a strategic provision in the Act to balance different goals. Regulation of fees for 100 per cent seats may discourage private players to open medical colleges or invest in quality education.
On the other hand, not regulating fees at all will deprive meritorious students who lack funds. Regulating fees for 50 per cent seats will help cross-subsidise education for students from socio-economically weaker communities. Auditing the accounts of private colleges will reveal the surplus revenue generated from ‘unregulated’ seats. This allows the NMC an indirect control over the rate of return that colleges would be able to earn, thereby checking ‘profiteering’ by private colleges.
Replacing corruption-plagued MCI
The National Medical Commission, which is set to replace the Medical Council of India (MCI), will have 20 members who will be appointed rather than elected. The NMC will also have five part-time members who will be elected from the state medical councils. Many argue that having nominated members in the commission undermines the democratic ideals and concentrates power in the hands of the central government.
This criticism is surprising for two reasons. First, most regulatory authorities in India and in countries like the United Kingdom, the United States, Canada and Japan are appointed and not elected. Second, as evidenced by several committee reports, the MCI is mired in various corrupt and unethical practices, primarily because its members are elected by the medical practitioners themselves. Since the regulator is elected by the regulated, it ends up prioritising the interests of doctors over those of the common people.
The MCI’s electoral process itself was fraught with problems. The current composition of the NMC, on the other hand, will allow the electoral process put in place for the five part-time members to be assessed over time, without compromising the authority’s functioning. Based on the assessment of the electoral process as well as the performance of these five members, the NMC would be in a position to rethink more objectively about the appointment of members.
While the NMC Act has the right first principles of incentives, information and accountability, the devil does lie in the details. Ultimately, the way we implement these provisions will play a decisive role in resolving contentious issues and in realising the objectives of these reforms. Rather than contesting the provisions, this is the time to hold a dialogue on the steps for implementation.