Above: A class in a medical college. Training would-be doctors is a key component of public health/Photo: akdn.org
Even as the Indian Medical Council (Amendment) Bill, 2019 seeks to ensure transparency in medical education, the fact is that private hospitals are increasingly getting commercialised even as patient-doctor trust gets eroded
By Dr KK Aggarwal
In a move to ensure transparency, accountability and quality in the governance of medical education, a new bill was passed by both Houses of Parliament—the Indian Medical Council (Amendment) Bill, 2019. It seeks to replace the Indian Medical Council (Amendment) Second Ordinance issued by the previous government. The Bill will supersede the Indian Medical Council (MCI) for a period of two years, during which a 12-member board of governors, instead of the earlier seven, will run the regulatory body for medical education. During this period, the board of governors shall exercise powers and functions of the MCI as assigned under the IMC Act, 1956.
It is a moot question as to why there is so much turmoil in taking control of medical education. Public health has two components—providing healthcare services and providing training and producing medical doctors. As per the Constitution, while the first is a state subject, the second is a central subject.
Even though it is a central subject, the MCI has autonomous control and is an elected body. Politicians and industrialists want to take control of medical education in India as it is an over Rs 1 lakh crore market. Till 2009, only non-profit trusts and societies could own medical colleges. But if one wanted to privatise them, the only answer was to take control of the autonomous MCI by politicians in the name of the central government.
The first step in this regard was taken in February 2010 when “firms under the Company Act” could enter the field, though without commercialising it. This was by way of non-profit companies. By this time, the MCI was dissolved and taken up by a board of governors to run it under the control of the government for the next four years.
In August 2016, there was a paradigm shift as the government allowed private for-profit companies to run medical colleges. This opened a new business opportunity for big private hospitals. In January 2017, another change took place. Now, existing non-profit trusts and societies already running medical colleges could convert them to profit-making ventures. This means that all non-government medical colleges had the chance to convert themselves into commercial ventures. But still the problem was the controlled fee instituted by state governments under a Supreme Court decision. In 2018, the MCI was again taken over by a board of governors.
This was supposed to continue for the next two years. Then, in May 2019, the government allowed two to four entities, including trusts, societies, companies or universities, to set up medical colleges. And thus started the commercialisation of medical colleges under private-public partnerships.
Still, this was not enough, and the government mooted an idea through the recent new educational policy for “fee regulation” to be done away with in professional courses. This will leave non-governmental medical education open to being totally commercialised.
Even if the original MCI is restored or the proposed National Medical Commission takes over, the damage is already done. Private medical education and healthcare services will remain commercialised. The current patient-doctor or hospital-doctor mistrust is also basically over the costly, unaffordable healthcare services in the private sector and non-availability of the same in the government sector.
The basic purpose of becoming a doctor is and will remain to alleviate the sufferings and pain of the patient. That means that emergent care cannot and should not be commercialised. But now with medical education being privatised and run for profit, the basic purpose of becoming a doctor does not remain intact unless he provides affordable emergent care.
There are enough opportunities for the health sector to earn from non-emergent care. This will give enough time to patients to arrange money for their treatment even when they are not covered by insurance.
But the “no admission unwritten policy” by most government hospitals for patients on ventilators, non-booked delivery cases, out of hospital patients on dialysis and patients requiring acute terminal care or long-term terminal care has encouraged commercial private hospitals to exploit the situation and charge exorbitantly for emergent care.
Commercialisation of medical education and private healthcare is acceptable as long as emergent care is left affordable, free or subsidised. Under Section 3 of the Essential Commodities Act, central and state governments have enough powers to take over emergent care and introduce a national list of essential drugs, devices, investigations and reagents needed for emergent care.
Under Article 21 read with Article 47, the central and state governments must provide free emergency care to all and reimburse those who are referred to the empanelled private sector due to non-availability of beds and under pre-agreed charges. Once the trust sets in, healthcare can go on smoothly. For example, in Delhi, there are two big trauma centres which can cater to all emergencies in the capital. Ever since this took off, we do not find patient-doctor mistrust in trauma cases.
Medical education is also dependent on allowing trainee doctors to see patients, especially those who are in an emergency situation. However, commercialising emergent care would mean that these young doctors won’t have enough to learn as the patient numbers will be fewer due to the costs involved.
Also, converting the MCI to a National Medical Commission (NMC) will be a move towards a non-federal structure. Today, all state governments, councils and universities have representation in the MCI. However, once the new Commission starts, these bodies will have practically no representation.
A non-autonomous, government-controlled NMC will tend to move towards commercialisation of medical education. If that happens, a student in any private medical institution will be brainwashed into thinking that his primary objective is to make money. But the medical profession is meant to alleviate pain and suffering and earning money should be the secondary aim.
The issue of geographic location of medical colleges can be tackled very effectively in case a national perspective development plan of five years is computed by the competent authorities. This should be strictly based on parameters of socio-economic backwardness and need-based analysis in the context of the mandate included in Article 371 sub-clause 2 of the Constitution.
—The writer is President, Heart Care Foundation of India, and President-elect, Confederation of Medical Associations of Asia and Oceania