The Narendra Modi government is determined to see the contentious National Medical Commission (NMC) Bill pass, expected to be tabled in Parliament during the upcoming Monsoon Session, to replace the much-criticised Medical Council of India (MCI).

Indications suggest that the government has amended certain sections of the bill to address the concerns expressed by the Indian Medical Association (IMA) and other medical experts.

According to sources, concerned departments of the health and law ministry are working in close coordination to make this bill a reality. Those within the government, revealed sources, have heeded to suggestions of taking up the bill in the Monsoon Session and are also prepared to take the route of an ordinance in case of another washout.

The bill has been the focal point of fierce debates as several medical experts decry it as an attack on the medical profession. On the other hand, proponents of the bill see it as a long-awaited redemption of medical education in India.

New bill vs old

In December last year, the Union Cabinet had approved the draft NMC Bill, which it said would bring the Indian health sector at par with world standards. In its original form, the bill had provided a provision for an Exit test, which was required to practice Allopathy after obtaining an MBBS degree.

The Exit test was meant for all MBBS students who wanted to practice Allopathy in the country. It was necessitated to check whether the candidates were qualified enough to practice. This test was also for the students who have completed their MBBS course outside India.

However, in the proposed bill, a significant amendment was made. A new provision was introduced that said that the final year MBBS exam itself shall be considered as the test for gaining eligibility to practice Allopathy; which shall be conducted uniformly throughout the country.

After the amendment, it has been made clear that the final year MBBS exam will be regarded as a prerequisite to practice Allopathy. Now, it said, there will not be a separate Exit test.

The provisions of the proposed bill will also put in place a search committee of 25 members, who will be elected under the chairmanship of the Union cabinet secretary. Out of 25 members, 21 will be essentially doctors.

In the original form of the bill, there was also a provision to bring effective and positive change in the primary health care by introducing a bridge course. As per this, those practising Ayurveda, Unani and Homoeopathy will be allowed to practice ‘Limited Allopathy’ after completing a bridge course.

The bridge course would train practitioners of Homeopathy, Ayurveda and other such fields in pharmacology and basic medicine. They will be trained and certified in such a manner that they can prescribe medicines for minor diseases.

The government, by doing this, wanted to address the scarcity of doctors by integrating various forms of medicine so that minor diseases could be treated at primary health centres.

But after strong protests from medical associations, the government has amended the bill and the decision in this regard has been left up to the respective state governments. They will be free to decide the modalities of the provision as per their requirements as it has been made non-mandatory.Another significant proposal is to regulate the fee structure in medical colleges. The amended bill has provisioned that for 50 percent of the seats in private colleges and deemed universities, the fee structure will be determined by the government. In the earlier version, it was 40 percent.

The remaining fifty percent has been left to private colleges and deemed universities to regulate. This has been done so as to not discourage private players from opening new colleges.

"If more colleges are there, then students will have more choices. There will be a healthy competition amongst them. Therefore, the fees will remain competitive," an officer associated with the drafting of the bill said.

New bills raison dêtre

In March 2016, the Parliamentary Health Committee submitted a report to the government in which they highlighted several anomalies in the working of the MCI and asked for its complete overhauling. Mincing no words, the report highlighted the fact that MCI has completely failed in its functioning as a neutral regulator.

The report states: "The need for major institutional changes in the regulatory oversight of the medical profession in the country is so urgent that it cannot be deferred any longer. The Committee is, however, aware that any attempt at overhauling the regulatory framework will face huge challenges from the deeply entrenched vested interests who will try to stall and derail the entire exercise. But if the medical education system has to be saved from total collapse, the Government can no longer look the other way and has to exercise its constitutional authority."

Taking cognizance of the report and given the seriousness of the matter, the government set up a committee headed by then Niti Aayog vice-chairman Arvind Panagariya. The bill was drafted with the suggestions and views of experts from the field. The group of experts, headed by the late Ranjit Roy Chaudhury, supported in the drafting of the bill and it was endorsed by the Parliamentary Standing Committee after extensive stakeholder consultations. Choudhury was a very reputed doctor as he was the first Indian doctor to receive a Rhodes scholarship. He was also the recipient of the Shanti Swarup Bhatnagar Award and the BC Roy award.

However, the Indian Medical Association (IMA) has now raised several objections against the proposed bill. Dr Ajay Kumar, former president of IMA and serving member of MCI, said, "an elected body of doctors is being replaced by a body that shall predominantly be constituted of nominated members. This is an attempt to demolish a democratic system by bringing it under the control of bureaucracy. It will completely undermine the independence of the doctors and and crush their morale."

Objections to proposed bill

One of the major trigger-points against the proposed bill is the provision that will replace an autonomous elected body of doctors with a body majorly comprising nominated members. The fact that 29 states will be represented only by five elected doctors does not help matters.

The provision of allowing non-Allopathic doctors to practice Limited Allopathy after the completion of a proposed bridge course is another point of criticism.

The proposal of conducting a uniform final MBBS exam has also been criticised as it undermines the reputation of various universities.

"This is such a dichotomy at play. On one hand, the government is talking about abolishing UGC, which has majority nominated members, and on the other, it is talking about replacing an elected body with a nominated one."

Several have registered strong resentment against the proposed bill and have predicted that if the bill is passed it shall be extremely detrimental to the medical profession.

Dr Naresh, a resident doctor at a famous government hospital in Delhi, said: "If the provision of bridge course is not dropped completely, it shall only promote and give legitimacy to quackery which shall pose a grave danger to the medical profession."

However, given the fact that the doctor-patient ration in India is extremely skewed, it should be noted that Limited Allopathy – a practice also utilised in the West – will only help in improving this imbalance.

In the GMC, a counterpart of the MCI in the UK, all members are appointed by the government. Half of the GMCs 12 members are doctors and the other six are non-doctors. Health is an important subject and cannot be left to doctors alone. Citizens must have a vital stake in the way the profession is conducted as well.

In the NMC, of the 25 members 21 are doctors, with key executive decision-making positions being reserved for doctors. Therefore, the role of doctors has not been diluted. In fact, this bill will rescue the regulatory body from the exclusive control of doctors.

According to an official at NITI Aayog, "There is an apprehension that the proposed bridge course shall promote quackery. But this will not happen as only those have been given license to practice Limited Allopathy shall be allowed to practice. There is a one-year imprisonment and Rs 5 lakh penalty for those violating this provision."

This kind of practice is prevalent in most developed nations. The cncept of a physician assistant (PA) is prevalent in America, where after completing two years of training and a certifying exam, a person becomes assistant to a doctor. Similar concepts exist in China, South Africa and Malaysia as well.As per a John Hopkins-PHFI study, primary health specialists are as effective as doctors in curing common diseases at primary health centers.

A senior officer of the health ministry said, "problems are being created because of some vested interests (of doctors) who do not want to give up their dominance. But the government is determined to pass the bill to help the people at large."

A 2015 Price Waterhouse Coopers report estimated that India is short of three million doctors and about six million nurses. It is now estimated that the shortage is now much higher. Only sixty percent primary health centers have one doctor whereas seven percent have none. It will take 50 years to clear the backlog if India continues to produce doctors at the current rate.

India has an estimated 55,000 MBBS seats. The country needs to produce doctors at a much improved rate to meet the scarcity. Though the rapid expansion in colleges has not translated automatically into quality, those institutions that did not invest in quality have now closed down or are facing closure.

We need to understand this while reducing regulatory barriers for entry of new medical colleges; but the premise that freedom to decide fee structure and allowing for-profit institutions will lead to rampant unethical practices is a flawed one. The uniformly conducted final year exam to check the merit and quality of students should address this problem.