Wednesday, August 26, 2015
Sunday, August 23, 2015
Saturday, August 22, 2015
Saturday, August 15, 2015
MARD moves court against govt's decision which nullifies chances of doctors going abroad to practice.
Doctors in Maharashtra are a peeved lot as the government has stopped issuing a key certificate that enables them to practice abroad. They say they have been singled out as the education of IIT and IIM students is also subsidised but they have no obligation to work in India.
Taking its fight to the courts, the Maharashtra Association of Resident Doctors (MARD) has filed a writ petition against the Centre for putting a halt on the practice of issuing the No Obligation to Return to India (NORI) certificate.
Any doctor who wants to work in a foreign country needs a NORI certificate.
Doctors say that the government's move is a violation of their fundamental right and that they are free to work and stay outside India.
"Why only doctors? The government spends a huge amount of money on IIT and IIM students too," said Dr Sagar Mundhada, president of MARD. "We had no choice but to approach the judiciary," he said, adding that while IIT and IIM students are not expected to give returns, doctors have a compulsory bond to serve the government for one year.
Last week, health minister JP Nadda had said that the NORI certificate will not be issued under any circumstances, except to those above 65 years of age. The idea behind the move is to prevent medicine's 'creamy layer' from migrating to greener pastures. Government authorities claim that the key reason behind the poor doctor-patient ratio in India is doctors shifting abroad.
"It is an extremely haphazard decision by the government. Instead of looking at why so many doctors prefer to work abroad, the government is taking a short cut which will not work," said Dr Amol Annadate, paediatrician and neonatologist practicing in Marathwada. A student of GS Medical College attached to the KEM hospital, Annadate too headed to Australia after his masters. "I worked there for over 8 months but I had the urge to do something for people in my country," he said, adding that this decision was not easy as the system in India 'bends and breaks you'.
"The government should mend the problems ailing the medical education rather than forcing decisions on doctors," said Annadate, who runs his own 250-bed medical facility and is the only paediatrician and neonatologist catering to a population of over 4 lakh people in five talukas of Marathwada. The Indian Medical Association has not taken a stand on the issue yet. However, Dr KK Aggarwal, president of IMA said that there was nothing wrong with the government expecting doctors to come back and serve the country. "IMA has not decided its stand. This is my personal opinion," he said.
Tuesday, August 11, 2015
Raghuram Nayak, who spent six years earning a medical degree in Ukraine, has spent the past three years trying to clear the examination that will allow him to practise medicine in India. In June this year, he failed the examination held twice a year a sixth consecutive time. Nayak studied medicine at the Zaporazhye State Medical University in Ukraine because his rank in the medical college entrance tests was not good enough to get an admission into government-run medical colleges in India and his parents could not afford the capitation fees sought by some private colleges.
He is among several thousand Indian medical graduates from foreign universities struggling to get a licence to practise in their homeland. They are claiming that they are victims of a screening examination that is unfair and whose grading practices appear tainted.
Members of the All India Foreign Medical Graduates Association today staged a demonstration at the National Board of Examinations (NBE), the agency that conducts the Foreign Medical Graduate Examination (FMGE), a multiple choice test that carries a maximum score of 300. Only candidates who score 150 or higher can practise medicine in India.
The association has cited the declining proportion of candidates who clear the examination each year to claim that its questions are intentionally designed to fail candidates rather than serve as a screening test to test their medical knowledge and skills. In June 2014, less than five per cent cleared the examination. In June this year, the pass percentage is less than 10 per cent, the association has said.
"Even post-graduate medical students in India cannot answer many of the questions we are asked in this examination," said Nayak, whose scores have remained below 147 the six times he has taken the test. The examination system is opaque. Some students receive the same marks year after year," he said.
Senior officials in the NBE were not available for comment. Two officials contacted by this newspaper on telephone said they were not authorised to speak to the media.
The association has drawn up a list of 31 candidates who have received the same marks in consecutive tests. One medical graduate obtained 140 out of 300 four consecutive times in the examinations held in September 2012, March 2013, September 2013, and June 2014. A medical graduate from Belarus got 144 out of 300 twice, in December 2014 and June 2015, according to documents released by the association.
"How can I get the same score twice? What is the probability of that?" the medical graduate from Belarus asked.
The association estimates that about 3,000 Indian students every year choose to study medicine in China, the Central Asian republics and Russia because medical education in those countries is less expensive compared with private medical colleges in India.
"For six years of studies, the cost there is less than or just about Rs 20 lakh," said Najeerul Ameen, a medical graduate from Russia and president of the association. "Here in India, the capitation fees in some of the private medical colleges run into a minimum of Rs 40 lakh," he said.
Nayak said he opted to study in Ukraine because his parents could not afford to pay Rs 60 lakh a private medical college had sought for a seat in the course leading to the MBBS degree.
A senior cardiovascular surgeon, who was once a member of the board of the NBE, said that an intentionally tough examination would suit the interests of many private medical colleges in India that charge capitation fees from students who don't make it into medical colleges on merit.
"This exam is a screening test and should be at the same level as MBBS test papers here in India, but it appears designed to address the brightest of candidates. This could explain the low pass percentage," said K Michael Shyamprasad, former vice-president of the NBE.
Shyamprasad and others, however, pointed out that some of the candidates with degrees from medical colleges in China or the Central Asian republics have limited clinical experience because they are unable to adequately communicate with local patients.
The association has demanded that the NBE should make available question papers to candidates so that they can, if they believe there is a need to, challenge the scores assigned to them.
Wednesday, July 29, 2015
Guest article by Dr Sanjay Nagral
The citizen is being shortchanged by the medical fraternity, but try telling the IMA that
A few paragraphs in a social sciences textbook of the NCERT for Class VII is hardly the kind of writing that makes major news. But when the Indian Medical Association (IMA) petitions the Prime Minister objecting to some sentences it should arouse curiosity not only because it seems like a trivial matter being blown out of proportion but because it suggests a lot about an organisation that has a critical role in health care discourse in India.
The issue is as follows. In the VIIth standard NCERT textbook chapter on the “Role of government in health”, under the sub-head “Private health facilities”, it says,
“In order to earn more money, these private services encourage practices that are incorrect. At times cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice”.
This is the bit that has provoked the IMA, the largest umbrella organisation of the practitioners of modern medicine in the country, to write to the Prime Minister and a host of other state functionaries demanding that it be deleted. In its letter the IMA warns, “The message which will go to the students is that “private sector fleeces money”. The letter goes on to explain how the cost of the public and private sector cannot be compared since the public sector is supported by state funds and hence the comparison is unfair.
In the narrowest sense what the IMA says is true but what the textbook has actually done with some clarity is to connect the basic logic of the private sector to unethical practices. What it is not doing is to locate the blame on the state, which over the years has encouraged an unregulated private sector by wilful neglect of the public sector, a point that the IMA misses in its rhetoric. It is, after all a 7th standard textbook and the authors were constrained by the need for simplicity and brevity.
IMA is pro private sector
The IMA has in its ambit all types of practitioners of modern medicine in India, public and private, specialist and general, rural and urban. Logically, therefore, it should represent the interests of all sectors. However, it is obvious that every time there is an attack on the private sector’s excesses, the IMA displays a prompt knee-jerk response, often in the form of victimhood. Whether it is the episode of ‘Satyameva Jayate’ on unethical practices where it called for an apology from Aamir Khan, or the nationwide strike the body called in 2012 to protest against the promulgation of the Clinical Establishment Act which sought to regulate the private sector, the IMA has consistently betrayed its bias towards the dominant entrepreneurial interests in health care. This obviously goes down well with its core constituency in the profession. On the other hand, the IMA has had nothing substantial to say about the complete decimation of the public health system with the resultant marginalisation of large sections of our people from access to decent care.
I was recently a member of a committee of the Maharashtra government which was set up to promulgate a modified state level version of the Clinical Establishment Act. Although it was one of the official briefs given to the committee, IMA representatives stonewalled all attempts to bring in some form of regulation of the fee structure in the private sector.
In many countries national medical associations have played stellar roles in promoting pro-people health policies, advocating patient’s rights and even resisting the state’s attempts to privatise health care as in the case of the British Medical Association during Margaret Thatcher’s time. Why is it then that the IMA has come to this sorry pass?
Control by market interests
One apparent explanation is that those with market interests are dominant in the leadership. Many office bearers of the IMA themselves own nursing homes and hospitals. But this has also been possible because the larger mass of medical professionals wittingly or otherwise have internalised the ideology of market medicine. Doctors from academia and those working in grassroots level NGOs who are capable of offering counter viewpoints have in a sense vacated this space. Many of them work and debate outside professional organisations offering alternatives but feeble internal resistance.
The state of the IMA may not be very different from other professional organisations in the country that primarily function as guilds to protect the narrow interest of their members, which can clash with the interests of the citizenry.
Many of these organisations are unable to think independently of the dominant market discourse as it applies to their profession. In that sense it may be unfair to single out the IMA. However, historically in India and across the world, medical professionals and organisations have provided resistance to dominant ideologies. Healthcare is one area of social endeavour where inequity is so stark that for medical professionals and organisations not to be concerned about the policies that nurture this would be shocking.
One wonders what Class VII students will remember from what has been taught to them as they grow up; some of them may even join the medical profession. It demands extreme innocence to assume that such textbook paragraphs will shape their long-term thinking. But when the principal association of lakhs of doctors across the country does not go beyond playing up to their constituency in response to a naive but important attempt to highlight the problems of private medicine in a school textbook, it reflects their lack of imagination – and more worryingly – their guilt.
Dr Sanjay Nagral is a surgeon practicing in Mumbai. He is a member of the Indian Medical Association and is on the editorial board of the Indian Journal of Medical Ethics
Guest article by Sarada Gopalan
We, the undersigned, medical professionals, educationist, academics, teachers, civil society organisations and other concerned individuals are writing to express our deep concern over the recent demand by the Indian Medical Association (IMA) for “immediate remedial action” on content included in the National Council of Educational Research and Training (NCERT) Social Science textbook on Social and Political Life (SPL) for Grade 7. The IMA’s demand to rewrite or delete the chapter is clearly unreasonable and unacceptable, as are the threats that the IMA has issued against the NCERT and the authors.
Chapter Two on the “Role of the Government in Health” in the above-mentioned textbook, sections of which the IMA is raising objections to, is part of a series of textbooks that were developed through a consultative process initiated by the NCERT, involving academics, teachers, researchers, government school teachers and civil society organisations with substantive experience and expertise in the thematic areas covered in the textbooks during 2005-08. These textbooks also underwent an independent process of systematic review prior to publication.
The SPL textbooks, as the name suggests, focus on themes related to social, economic and political life in contemporary India building on the well-recognized pedagogic principle that children learn best through concrete examples. The SPL textbooks aim to develop the abilities of children to critically engage and analyze these realities in keeping with the tenets of the Constitution of India. The chapter that is under contention, focuses on the critical role that equality exercises in Indian democracy and each of the five units of the book highlight a particular issue related to elucidating this theme. Health is one of the issues discussed and is included in Unit 2 on ‘State Government’, which contains two chapters on the “Role of the Government in Health” and “How the State Government Works”.
As the titles make clear, these chapters aim to present and discuss the government’s role and responsibilities around providing quality health care for all in a democracy.
Specifically, the chapters attempt to get students to begin thinking critically about inequities in health care, including concerns of availability, accessibility and quality. In presenting these concerns, the chapter includes a discussion of the private and public facilities, which comprise the health sector in India. The objective of the chapter is not a comparison of the public and private health care sectors, rather the chapter seeks to reiterate the state’s responsibility in a democracy and emphasize the implications of the withdrawal / insufficient provisioning by the government for public goods, namely health care. Reference to this central idea can be found in the “The Story of Hakim Sheikh”, where many government hospitals refused to admit him for treatment. This real case study is used as a running thread through the chapter and illustrates that denial of health care violates the constitutional provision for the right to life. This landmark judgment by the Court would encourage the student to think of the wider public interest and not accept the implications of these situations as natural.
The IMA’s allegations and demands are unfortunate and based on a selective reading of the chapter. The IMA has raised objections to a couple of lines regarding the costs of treatment in the story board – however, following the story board are questions that invite students to look at it in an open ended manner, relate to the social context and bring their own experience in an illness to the classroom. The storyboard is an important educational tool that facilitates students’ understanding of the diversity and inequalities evident in access to health care (not a simple public versus private distinction as has been understood by IMA); and the government’s role in health care provisioning, governance and accountability.
Further, abundant evidence exists that indicates the severe costs of health care in the private sector. It is a known fact that private health care is largely unaffordable for the vast majority of Indians. Indeed, out of pocket expenditure on health in India is one of the highest in the world, and health care costs contribute to indebtedness for a significant portion of our population. According to the World Health Organization (WHO) India National Health Accounts (NHA) data for 2013, out of pocket (OOP) expenditure as percentage of Private Health Expenditure in India, was 86 percent. On average, a much higher amount (four times) is spent for treatment per hospitalized case by people in the private (INR 25850) than in the public (INR 6120). The average cost of hospitalization for childbirth in rural areas is Rs. 1587 and Rs. 14778 and in the urban areas Rs. 2117 and Rs. 20328 in public and private hospitals respectively (NSSO). Health Surveys have also pointed to, for example, that the number of caesarean deliveries in private hospitals was almost three to 10 times more as compared to government hospitals (AHS2012-13). A World Health Organization study, which reviewed 1,10,000 births from nine countries in Asia including India in 2010, revealed more than 60 per cent of the hospitals studied, where these C-sections took place, did it for financial gains and not because it was required.
The IMA’s objection is to sentences which discuss the private sector and state:
“In order to earn more money, these private services encourage practices that are incorrect. At times, cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice.”
Evidence of such practices is widely available including in a recently released book-based on interviews with 78 doctors across India also includes narratives of “widespread irrational drug prescribing, kickbacks for referrals, and unnecessary investigations and surgical procedures”.
Further, IMA’s allegation that students will be “brainwashed” against the private health sector, is unfortunate and unfounded. It has been long established that students, however young, bring to the classroom knowledge and experience that the classroom process needs to facilitate as part of the process of learning. The IMA’s objection to one frame from a storyboard is not only disingenuous but completely misunderstands and disregards the educational requirements of textbooks.
Undoubtedly, there are doctors who conduct ethical private practice, as there are government hospitals that are run effectively. The chapter as currently written provides enough questions in the text to enable students to engage in a discussion based on their health care experiences thereby allowing them to agree or contend with the information that the chapter makes available and to understand that there are implications for society that faces such inequality in access including costs for a basic need, especially given the current environment that is encouraging of privatisation- indeed corporatization of health.
As the above data show, a large section of society in our country is denied basic health care. The IMA’s demand will result in students receiving a distorted and incorrect representation of issues that the Indian health care sector continues to grapple with. It would also work to stymie the development of critical thinking skills in students through engaging difficult concepts like ‘equality’ and ‘democracy’ through their own experiences. Sound and proven educational principles should not be allowed to be jettisoned by particular interest groups, irrespective of their political and ideological position.
We, therefore, reiterate the unacceptability of the demands by IMA and oppose any attempts to undermine the intent of these textbooks. We urge the government to reject the demand by IMA to rewrite or delete Chapter 2 on ‘Role of the Government in Health’ in the Social and Political Life Class 7 textbook.
Signed by the Textbook writing team for the SPL textbook for Grade 7:
Dr. Sarada Balagopalan (Chief Advisor), Arvind Sardana (Advisor), Dipta Bhog, N Sarojini, Malini Ghose, Prof Krishna Menon, Prof Mary John, Prof Anjali Monteiro and Sukanya Bose (Members)
and endorsed by 213 others