Friday, Dec 02, 2022

Curing the system

India needs more doctors. National Medical Commission will address the issue, transform medical education

National Medical Commission is no cure-all, many important questions remain Doctors and students from the Indian Medical Association (IMA) shout slogans as they stage a protest against the National Medical Commission Bill (NMC). (File)

Parliament has just passed the National Medical Commission (NMC) Bill to replace the Medical Council of India (MCI), a body that has been held responsible for the short supply and inefficiency in medical education. It is also widely accepted that MCI has been unsuccessful in maintaining and enforcing uniform standards in medical education. With the passage of the NMC Bill, we can hope to see a significant transformation in the medical education system.

With around 70 per cent of the 100-plus-strong MCI comprising of elected members, the body has been afflicted with an inherent conflict of interest. Those being regulated would elect their regulators, with professionals who might have been better suited for the job often staying away. In contrast, the 25-member NMC will consist of doctors and experts from associated fields who can guide medical education in the country towards global excellence.

Moreover, several checks and balances will be put in place to ensure that the NMC functions in an objective, transparent and ethical manner. For instance, it will not be possible for the chairperson and other members nominated by the Centre to be re-nominated. Further, while in the MCI, the presence of merely 15 out of 100 plus members was adequate to make the decisions of a meeting valid, the NMC Bill necessitates the agreement of 13 out of 25 members for a decision to be taken. The NMC will also meet every quarter as opposed to a minimum of once a year for the MCI. Members of the NMC will be required to declare their assets and liabilities as well as any conflicts of interest.

The MCI assessed institutions on the basis of their adherence to a set of pre-defined criteria that focused overwhelmingly on inputs such as infrastructure and teacher salaries. There was little emphasis on ensuring the quality of teaching in medical colleges and delivering world-class learning outcomes. Under the NMC, the Medical Assessment and Rating Board (MARB) will develop a system for the assessment and ranking of medical colleges. MARB will also be responsible for granting permission for setting up new medical colleges and starting postgraduate courses.

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A key feature of the NMC Bill is an all-India final-year MBBS examination that will test for common standards of knowledge and skills among doctors. This is crucial because only a common exam can ensure that doctors across the country have a shared minimum level of skills. The National Exit Test (NEXT) will serve as an entrance test for postgraduate courses as well as screening mechanism for foreign medical graduates.

The composition of the NMC (75 per cent doctors representing central and state institutions and health universities) will ensure that adequate weightage is given to theoretical and clinical skills in NEXT. There is a three-year timeframe for operationalising NEXT, which provides ample opportunities to define the precise contours of the examination.

India has a doctor-population ratio of 1:1,655; the World Health Organisation standard is 1:1,000. Moreover, there is a considerable skew in the distribution of doctors, with the urban to rural doctor density ratio being 3.8:1. We are finding it impossible to engage doctors and specialists in Aspirational Districts.


The capital cost of setting up a new medical college is almost Rs 5 crore per bed. This is mostly because of extensive land and infrastructure requirements. The Minimum Standard Requirements mandated by MCI are irrational and have proved to be the biggest impediment in the establishment and expansion of medical colleges. The existing norms for infrastructure need to be rationalised to give an impetus to opening new medical colleges based on existing infrastructure.

Further, we need to review the compliance requirements for establishing and operating medical colleges. A comparison with international benchmarks reveals that stipulations such as maximum number of medical seats allowed per medical college, OPD and IPD requirements as well as faculty norms are too rigorous in India.

The NMC Bill includes several path-breaking recommendations to provide greater flexibility to medical institutions, increasing the number of doctors while ensuring quality. For instance, a one-time permission will be required by medical colleges for establishment. It will also be possible for them to increase the number of seats on their own up to a cap of 250 and start postgraduate courses.


For expanding the number of private medical seats while balancing the interests of meritorious students who cannot afford the fees, the NMC will regulate fees for 50 per cent of seats in all private and deemed universities. In parallel, efforts to create more medical seats in the government sector will continue. Over the last five years, the government has invested more than Rs 10,000 crore in medical education and 21 new AIIMS are being established at a cost of Rs 30,000 crore.

Despite the best efforts, it could take up to 20 years to ramp up the supply of doctors. Currently, most of our rural and poor population is denied quality care, leaving them in the clutches of quacks. Self-styled doctors without formal training provide up to 75 per cent of primary care visits. Moreover, at present, 57.3 per cent of personnel practicing allopathic medicine do not have a medical qualification.

In this context, it is noteworthy that the NMC will have the authority to grant a limited licence to Community Health Providers (CHPs) who can deliver preventive and primary health services. Thailand, the UK and China permit CHPs to deliver health services, thereby reducing the burden on specialists and improving health outcomes. Similar results have been achieved in Chhattisgarh and Assam. Of course, the quality of CHPs will be regulated tightly.

Undoubtedly, the passage of the NMC Bill will prove to be a landmark moment in the process of fixing the flawed medical education system. Most importantly, its implementation will go a long way in augmenting the supply side for quality human resources in the health sector.

(Kant is CEO, Niti Aayog. Views are personal)

First published on: 15-08-2019 at 12:03:44 am
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