A scathing indictment of the Medical Council of India shows why health care in India is plagued by corruption and malaise. Urgent steps need to be taken to revitalize this vital sector
By Ajith Pillai
What ails our health care system is a question that defies a simple answer. There are far too many diverse aspects to the humungous problem faced by the medical system in the country to be treated by a single prescription. But one basic building block which needs to be rebuilt and put through drastic surgery is medical education. The expert view is that if it is put on the right track it could have a bearing on the sector and its overall well-being.
The Parliamentary Standing Committee (PSC) on health and family planning which tabled its report in parliament last month virtually echoed the same view. The committee, comprising of 31 MPs from the Lok Sabha and Rajya Sabha, pointed out that “despite having the most number of medical colleges in the world” (381 colleges offer the MBBS course) and 9.29 lakh doctors enrolled on the Indian Medical Register, India has a shortage of doctors who are an “important cog in the wheel of the health care system”. Result: access to health care, especially to the vulnerable and poorer sections of the country, has been grossly inadequate.
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Among the feedback the PSC received on the crisis facing medical education and the profession were the following: failure of the current system to produce doctors, including specialists and super specialists, in adequate numbers and of requisite quality; deficiency of teachers in medical colleges and poor regulation of undergraduate and postgraduate education.
It was also informed about the disconnect between medical education and the health system; absence of proper screening and admission procedures in private medical colleges; prevalence of capitation fee for admission in private medical colleges in violation of the law; ethical issues like over-investigation and over-treatment in private hospitals and inadequacy of self-regulatory processes in the medical profession.
To bring about a change in the current situation, the PSC, which met several stakeholders, experts and visited medical colleges, has come to the conclusion that the Medical Council of India (MCI) which regulates medical education must be reformed. It currently lacks any accountability and has failed to discharge its mandated responsibilities and is widely perceived as corrupt. The arrest of Dr Ketan Desai, president of MCI, a few years ago by the CBI on graft charges was a case in point.
According to the PSC, the very structure of MCI has to be changed. At present, it has elected representatives. As corruption is rampant in elections, money power plays a decisive role in who dominates MCI. Ideally, it should be represented not just by educational institutions but all arms of the profession, including the government.
Observes the report: “Regulators are required to have the professional excellence and moral authority to address complex issues related to content, standards, quality, competencies and skills of medical education and practice. But the MCI, as presently elected, neither represents professional excellence nor its ethos. The current composition of the Council reflects that more than half of the members are either from 21 corporate hospitals or in private practice.”
The PSC report also noted that even doctors nominated to represent state and central governments have been nominated from corporate private hospitals which are “not only highly commercialised and provide care at exorbitant cost but have also been found to be violating value frameworks”.
Warped and vested priorities have ensured that institutions that produce doctors are unevenly distributed. The committee was told by an expert that “six States which represent 31 percent of India’s population have 58 percent of the MBBS seats; on the other hand eight states which comprise 46 percent of India’s population have 21 percent of MBBS seats”. In all, there are 63,800 medical graduate seats in the country—25,082 in government institutions and 38,715 in private colleges.
With private colleges mushrooming (180 as per last year’s figures), the PSC felt that there was an urgent need to streamline admissions and to root out capitation fee, much of which is paid under the table. This corrupt practice is what has made setting up medical colleges a lucrative business. Registration and approval of institutions run by dubious promoters by the MCI is also ridden with allegations of graft, it said.
To quote the PSC report: “It is public knowledge that the majority of seats in private medical colleges are allotted for a capitation fee going up to Rs 50 lakh and even more in some colleges despite the fact that the capitation is not legal. This capitation fee is exclusive of the yearly tuition fee and other expenses. The Committee observes that the issue is not just about capitation fee. This has serious implications for our whole system of medical education and healthcare…If a unitary Common Entrance Exam is introduced, the capitation fee will be tackled in a huge way.”
Even the quality of education imparted was found wanting. The committee found that the syllabi for the MBBS course needs to be revised every four to five years but nothing of that kind has been done in the last 14 years. Thus, there has been no innovation or change in the methods of teaching over the years. Skill training is not happening in the present curriculum. “So, today’s MBBS (doctor) is a zero in knowledge and does not have basic competencies like conducting a normal delivery or suturing wounds,” the report pointed out.
There is also a deficiency of teachers. According to the report, it is approximately 30-35 percent in all colleges and perhaps even more. The situation is such that even governments feel compelled to temporarily mass transfer teachers from one state-run college to the other to fulfill the criteria of number of teaching staff when the MCI comes to inspect. Keeping fake rolls of medical teachers and showing expenditure under the salary head is a common tactic adopted by managements of private medical colleges.
As for inspections carried out by the MCI, the less said about this farcical exercise, the better. In fact, from sanctioning of colleges to quality checks, there is rampant corruption. The report said: “Corruption was there when there was sanctioning of medical colleges, or increasing or decreasing seats. The committee has also been informed that private medical colleges arrange ghost faculty and patients during inspections by MCI and no action is taken for the irregularity.”
Whether it is shortage of teaching staff or lack of doctors to serve in the public health care system, the committee has stressed the need for better remuneration for doctors to refrain from plunging into the more lucrative private sector or set up practices of their own. Also, it feels, the MCI needs to amend its rigid stance of employing only full-time teachers in medical colleges. Instead, it should include experts on the faculty on a part-time basis. As things stand, the committee was told, that a heart surgeon of Dr Naresh Trehan’s eminence cannot teach unless he gives up all his other commitments!
On the question of doctors violating ethics of the profession, the PSC report notes that the MCI has been rather tardy. “The oversight of professional conduct is the most important function of the MCI. However, the MCI has been completely passive on the ethics dimension which is evident from the fact that between 1963-2009 just 109 doctors have been blacklisted by the Ethics Committee of the MCI.”
The report goes on to elaborate on the ethical question: “Due to crass commercialization of the health sector, many unprincipled doctors and private sector hospitals have lost their moral compass and overcharge or subject their hapless patients to unnecessary surgeries and diagnostic procedures. The instance of unethical practice continues to grow due to which respect for the profession has dwindled and distrust replaced the high status the doctor once enjoyed in society.”
In the final diagnosis, the PSC has recommended game-changer reforms. It is of the view that the MCI has to be recast since no “tweaking” of the existing system can help. “The Committee is convinced that the much needed reforms will have to be led by the Central Government. The MCI can no longer be entrusted with that responsibility in view of its massive failures. The people of India will not be well-served by letting the modus-operandi of MCI continue unaltered to the detriment of medical education and decay of the health system.”
The PSC has recommended immediate and far-reaching changes. The ball is now in the government’s court.