Government Reforms Health Sector

Abhishek Kumar

The full potential of a nation can only be realized if its citizens are strong and healthy. However, in a country where about 276 million people are living below the poverty line, ensuring adequate healthcare access across various sectors is indeed a tough job. A number of government sponsored schemes have been introduced in the past, but most of them were ridden with numerous flaws. This posed consistent and significant challenges. It was primarily in order to counter these difficulties and provide an efficient healthcare system that the Ayushman Bharat health insurance scheme and a bill on National Medical Council was recently launched.

Ayushman Bharat - National Health Protection Mission will have major impact on reduction of Out of Pocket (OOP) expenditure on ground of:

• Increased benefit cover to nearly 40% of the population (the poorest & the vulnerable)

• Covering almost all secondary and many tertiary hospitalizations (except a negative list)

• Coverage of 5 lakh for each family (no restriction of family size)

This will lead to increased access to quality health and medication. In addition, the unmet needs of the population which remained hidden due to lack of financial resources will be catered to. This will lead to timely treatments, improvements in health outcomes, patient satisfaction, improvement in productivity and efficiency, job creation thus leading to improvement in quality of life.

NMC Bill 2019, replacing the controversial Indian Medical Council (IMC), aims to regulate medical education and practices in India. While the bill introduces some path-breaking provisions, not all are happy. A section of doctors have vehemently opposed this idea and feels that the Bill is dominated by central government nominees. Most, who have been tracking the development in relation to medical regulations, appear in favor of a system that replaces the Medical Council .

‘One-Nation-One-Exam’ in medical education.:

Entrance examinations:  There will be a uniform National Eligibility-cum-Entrance Test for admission to under-graduate and post-graduate super-speciality medical education in all medical institutions regulated under the Bill.  The NMC will specify the manner of conducting common counselling for admission in all such medical institutions.

The Bill proposes a common final year undergraduate examination called the National Exit Test for the students graduating from medical institutions to obtain the license for practice.  This test will also serve as the basis for admission into post-graduate courses at medical institutions under this Bill.

Community health providers:  Under the Bill, the NMC may grant a limited license to certain mid-level practitioners connected with the modern medical profession to practice medicine.  These mid-level practitioners may prescribe specified medicines in primary and preventive healthcare.  In any other cases, these practitioners may only prescribe medicines under the supervision of a registered medical practitioner.

Second, concerns have been expressed over the limited licence to practice for community health providers. We have to appreciate that even with about 70% of India’s population residing in the rural areas, the present ratio of doctors in urban and rural areas is 3.8:1; 27,000 doctors serve about 650,000 villages of the country. A recent study by the World Health Organisation shows that nearly 80% of allopathic doctors in the rural areas are without a medical qualification. The NMC Act attempts to address this gap by effectively utilizing modern medicine professionals, other than doctors in enabling primary and preventive health care. Evidence from China, Thailand and the United Kingdom shows such integration results in better health outcomes. Chhattisgarh and Assam have also experimented with community health workers. 

Fee regulation

IMC Act, 1956 has no provision for regulation of fees. As a result, some states regulate the fees of some seats in private colleges through MoUs signed with college managements. In addition, the Supreme Court has set up committees chaired by retired High Court Judges to fix fees in private colleges as an interim measure. Deemed to be Universities claim that they are not covered by these committees.

Nearly 50% of the total MBBS seats in the country are in government colleges, which have nominal fees. Of the remaining seats, 50% would be regulated by NMC. This means that almost 75% of total seats in the country would be available at reasonable fees.  In the spirit of federalism, the State governments would still have the liberty to decide fees for remaining seats in private medical colleges on the basis of individual MOUs signed with colleges on the basis of mutual agreement.

We need to balance the interests of the poor but meritorious students and the promoters of the private medical colleges in order to expand the number of seats on offer. It is not correct to assume that colleges would be free to arbitrarily raise the fees for unregulated seats. The transparency provided by NEXT results would lead to regulation of fees through market forces. Colleges would have to provide quality of education commensurate to the fees charged by them, otherwise there would be no takers for their management quota seats.

Rating would be provided by MARB for medical institutions based on the standard of education/training.  This will serve to regulate fee through market forces.

Any affirmative action has to meet the test of reasonability. India has a large middle class population. The government of the day is duty bound to create infrastructure for all segments of society.

While need for solicit private investment in the medical education sector and want private medical colleges to be financially viable, this government has not shied away from its responsibility to create more seats in the government sector. Government have invested more than Rs 10,000 crores in creating government seats in the past five years, and are also setting up 21 new AIIMS at a cost of over Rs 30,000 crores to boost the medical education sector. This trend of creating government seats will continue in future.

There is no question of NMC Bill making medical education a preserve of the rich. On the contrary, it is common knowledge that before the reforms of NEET and common counseling were introduced by our government, rich students who could afford to pay huge and unrecorded capitation fees were able to secure admission to private medical colleges. Our reforms have eliminated the role of black money in medical education and the NMC Bill will provide statutory force to the reforms which have been carried out.

Another concerns over issue of overriding powers of the Centre in the context that the Medical Council of India, even if directed by the government on critical matters, In public emergencies, citizens expect the government to address issues. The use of such authority would follow the principle of natural justice: the NMC’s opinion would be sought before giving directions.

The efforts of successive governments have now culminated with the NMC Act replacing the IMC Act. There is no denying that medical education needs continuous reforms in order to usher in improvements in health care. There cannot be just one solution. The NMC Act is a serious attempt to meet the primary need of more medical professionals in the country; it is a just beginning.It will brings transparency, accountability and quality in the governance of medical education in the country. It is a progressive legislation which will reduce the burden on students, increase the number of medical seats and reduce cost of medical education.