Thursday, February 11, 2016

What spurred Rs 12,000 crore medical education black market

Recently, PG Times had conservatively estimated the scale of the black economy in medical seats at about Rs 12,000 crore. How has this black market come into being? It is thanks largely to a massive expansion in private medical education in the 15 years from 1996 to 2010. Nearly 60% of the private medical seats now available were added during this period.

The expansion followed a crucial change in the Indian Medical Council Act in 1993, which gave the Medical Council of India (MCI) complete control over the process of recognising new colleges and courses. Incidentally, the 15-year period was one in which Dr Ketan Desai and his close associate Dr Kesavan Kutty Nair held sway over MCI. Desai was twice removed from the post of MCI president on allegations of corruption, though he has never been convicted on these charges.

At the time of independence there was just one private medical college, CMC Vellore, and even at the beginning of the 1980s there were only 11 of them.

MCI was established in 1934 under the Indian Medical Council Act 1933, later replaced by the 1956 Act of the same name. Though conceived as an advisory body to the government on matters related to qualification and registration of medical practitioners, the council has acquired greater powers over time through amendments of the Act. The crucial one was in 1993, by which a new section 10A was introduced laying down stipulations for establishment of new medical colleges and courses of study. With this, MCI gained complete control over the process of establishing new medical colleges, and state governments, which played a larger role earlier, were reduced to just issuing no-objection certificates. This was followed by regulations brought in by the council to implement section 10A, by which curriculum and faculty requirements came under its purview and gave it the power to inspect colleges.

The years since then have seen private entrepreneurs setting up colleges as business ventures. Between 1996 and 2010, 114 private colleges were opened and their total number jumped two and half times. Thus, private colleges came to account for more than half the medical colleges in the country. In the first decade of this millennium (2000-09), 91 private colleges were opened, compared to just 62 from independence till 1999.

The 1990s also saw the rise of Dr Desai in MCI. In 1996, Desai, who had been an MCI member from 1987, became the president. This stint was cut short by the Delhi high court, which ordered his removal on charges of corruption in November 2001.

While going through the minutes of the meetings of the council, the court observed: "The president has managed and manipulated the affairs of the council in a manner that he exercises complete control... The executive committee is being used to legitimise his activities... who in turn is using his position to make illegal monetary gains..."

The court appointed retired Maj Gen SP Jhingon as administrator of MCI. He was relieved by November 2002. Even during Jhingon's tenure as administrator, the person who headed the executive committee meeting was Dr Kesavan Kutty Nair, Desai's associate. Dr Nair continued to head the meetings of the executive committee right through to 2007 when Desai came back to the council as a member. The executive committee, in the intervening period, included several persons known to be close to Desai, including Dr Ajay Kumar and Dr Ved Prakash Mishra.

By March 2009, Dr Desai was back as MCI president and his name for the post was proposed by Dr Rani Bhaskaran, wife of Dr Nair, and Dr Ved Prakash Mishra. Dr Kesavan Kutty Nair became the vice-president. But by April 2010, Desai was arrested yet again on charges of corruption and MCI was disbanded and replaced by a board of governors (BoG) consisting of eminent doctors nominated by the Central government.

The BoG's stint till November 2013 coincided with the government's renewed efforts to boost facilities for medical education in the public sector. Thirty-five government colleges adding 3,700 seats and 44 private colleges adding 5,750 seats were approved. By 2013 end, the BoG was replaced by the current council. In the last two years, 18 government colleges adding 2,150 seats and 17 private colleges adding 2,450 seats were approved.

The rush to boost medical colleges and MBBS seats in the public and private sector has been marred by persistent reports of colleges being run with inadequate faculty, facilities and even patients to provide clinical material. As many as 27 colleges, all private, were barred from taking in students in 2015-16 due to deficiencies spotted during inspections. Those in the field say these 27 are merely the tip of the iceberg and the rot is deeper and wider in private medical education.

Wednesday, February 10, 2016

MCI's code of ethics gives docs way to accept freebies

The recently notified 'new' ethical guidelines of the Medical Council of India (MCI) are being touted as a bid to punish doctors accepting freebies from pharma companies. However, these guidelines, doctors fighting corruption in the profession point out, will legitimise doctors' associations taking money from the pharma industry.
While the guidelines elaborate the quantum of punishment for doctors on the basis of the value of favours or freebies received from pharma companies, they also include an amendment that ensures that doctors' associations are beyond the MCI's jurisdiction.
Under the Societies Registration Act, it takes just seven people to form an association. In effect, what is barred for an individual doctor can be done as soon as seven or more of them get together to form a society or association.
The guidelines are actually five years old, but were notified in the official gazette on February 1. Without them being notified by the government, they could not come into effect. As a result, the council could not allow associations to go scot free claiming that it has no jurisdiction over them.
These guidelines were framed by the MCI in March 2010, when Dr Ketan Desai, twice removed from the president's post on charges of corruption though not convicted, was heading the council. The new guidelines were meant to amend the Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002. The first amendment was to delete the words "and professional association of doctors" from section 6.8 of the Code of Medical Ethics Regulation 2002. Earlier, this section read: "code of conduct for doctors and professional association of doctors in their relationship with pharmaceutical and allied health sector industry". In the amended version, the words "professional association" have been deleted.
This was within months of the new code of ethics barring doctors and professional association of doctors from taking gifts and sponsorships from pharmaceutical and health sector industry being published in the gazette on December 14, 2009. According to the minutes of the central working committee meeting of the Indian Medical Association in June 2010 Dr Desai when asked about clause 6.8 regarding organisations had "promised that this would be rectified". That promise has now been fulfilled.
"This is a national shame. You are allowing a gang to do the corruption but not one person. It is plain and simple legalising of corruption. This gives legal sanction to pharma companies to bribe doctors and the poor will suffer as companies will go on paying doctors and the money will come from the pockets of the common man," said Dr G S Grewal, president of the Punjab Medical Council.
"This sudden hurry to notify the five-year-old guidelines is because it was recently reported in the media that the council cannot exonerate the IMA and other doctors' associations for taking money as the amendments were not notified.
Once notified, these so-called ethical guidelines may help to legitimise pharma bribes for doctors' associations," explained Dr KV Babu, who had complained against the IMA taking money from Pepsi and Dabur to endorse their products.
The absurdity of making something illegal for individual doctors but legit for their associations was pointed out in a submission made by the MCI in the Delhi High Court in 2011. It said, "what is not allowed to be done directly, cannot be permitted to be done indirectly" and that it was unsustainable to argue that what an individual doctor cannot do can be done by doctors forming an association.
This submission was in a case involving the IMA taking money from private companies and was made during the tenure of the Board of Governors (BoG), who ran MCI after it was disbanded in 2010. Yet, the reconstituted medical council that replaced the government-appointed BoG in 2013 reverted to the stance that it had no jurisdiction over doctors' associations.

IAP launches ACE 10/10 - healthcare initiative for adolescents

The Indian Academy of Pediatrics (IAP) today launched ACE 10/10, a major healthcare initiative aimed at adolescents. The initiative will focus on driving awareness around three key pillars of Health, Nutrition and Vaccination as essential to comprehensive adolescent care.

The ACE 10/10 initiative was jointly unveiled by Dr. Pramod Jog (IAP President 2016), Dr. Anupam Sachdeva (IAP President Elect 2016) and Dr. Bakul Parekh (IAP Secretary 2016).

Speaking on the occasion, Dr Pramod Jog, said, "With 1 in 5 people in India being adolescents, there is a need is to ensure that the foundations laid during adolescence are strong enough as they are the future of the country. While what happens during the early years of life impacts adolescents' health and development, what takes place during the adolescent period affects health during the adult years and even influences the wellbeing of the next generation. Paediatricians play an important role as trusted advisors to parents, and we believe that they can be key drivers of change in the society. IAP is proud to launch a comprehensive program that will catalyse the collective strength of paediatricians as key influencers to effect an impactful change in the health and well-being of adolescents as a significant segment of our society."

"Adolescence is one of the most beautiful and poignant phases of one's life, yet it is also one of the most difficult and turbulent phases. It is a time of growth, experience, and fulfilment associated with leaps and falls; a period when new relationships are made and old ones tested and strengthened. This is precisely that time when the individual yearns to touch the sky, rebels and also starts risk-behaviour with serious consequences. Pediatricians, as gatekeepers, have the pleasant responsibility of making this journey better and easier for both the teens and their parents and teachers by empowering them. Pediatrician can be that someone whom adolescents can trust and confide in, someone who can guide and is non-judge-mental. And to accomplish this task we need to equip ourselves," Dr. Jog added.

India has the world's largest adolescent population with around 236.5 million population in the adolescent age group of 10-19 years. The ACE 10/10 initiative aims to create 'Adolescent Ambassadors' in the paediatrician community across each state for influencing the care and health needs of adolescents. The program will impart training to paediatricians across all the states with a view to impacting the well-being of adolescents in the country.

Expressing concerns about the neglect of adolescent healthcare in the country, Dr. Jog said "Overlooking the health of adolescents is a key reason for unmet goals in the area of adult health. Adolescence is a significant opportunity to improve the health of a child in the second decade of his life. I am happy that IAP has come forward to design such an initiative to address healthcare concerns among adolescents while suggesting preventive measures to help protect them from diseases. Healthy, educated adolescents will grow into a resource pool of valuable individuals with the potential to contribute to the betterment of their families, communities and country."

Under the program, paediatricians will be trained on providing standard care for adolescents across three pillars - Health, Nutrition and Vaccination. The program will focus on encouraging paediatricians to educate parents on the importance of comprehensive adolescent care, including ensuring the completion of vaccination as a means to protect them from some critical diseases.

The ACE 10/10 program will be rolled out starting March by the Indian Academy of Paediatrics.

The ten behaviours that the ACE 10/10 program recommends for parents:

  1. Encourage eating wholesome breakfast
  2. Discourage foods high on sugar, fat and salt to avoid weight gain
  3. Instill habit of having at least 6-8 glasses of water or fresh juices
  4. Ensure regular sound sleep of 8 hours ; discourage sleeping too much or too little
  5. Monitor school performance and studies every day
  6. Be observant of change in the behaviors; ensure communication & use teachable moments
  7. Know and stay connected with the friends
  8. Ensure 3 visits to the Paediatrician at the 10th year for physical and psychological check-up and then yearly visits to monitor growth and development
  9. Vaccinate boys and girls with Tdap vaccine
  10. Vaccinate girls at 10 years with HPV vaccine

Monday, February 8, 2016

MCI recommendation: Health Ministry clears common test for admission into medical colleges

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In a significant move, Union Health Minister J P Nadda has approved the Medical Council of India’s recommendation for an amendment to the Indian Medical Council (IMC) Act that will empower it to hold a nationwide common medical entrance test.

The health ministry has prepared a draft cabinet note to be circulated among the ministries.

The proposed amendment will pave the way for a one-country, one-medical entrance plan, for both undergraduate and postgraduate medical courses in all colleges, including private colleges and deemed universities.

The MCI has told the government that it could either notify an existing examination, like the All India Pre Medical Test (AIPMT), as the common test or notify a new one.

The IMC Act governs the functioning of the MCI, which is the medical education regulator. Under the current Act, its role is limited to finalising the medical curriculum, while the states and individual colleges can devise their own admission procedures.

But in October last year, the MCI general body passed a proposal to amend the Act in order to empower it to conduct a common entrance test.

An earlier attempt to hold a common entrance test did not pass muster with the Supreme Court as it was undertaken by just notifying a change in the rules, without actually amending the Act.

The National Eligibility cum Entrance Test (NEET) (PG) was held in November-December 2012 and NEET (UG) in May 2013. About 80 petitions were filed by minority institutes, private colleges and some state governments, which went to the Supreme Court.

Quashing NEET in July 2013, a bench of then Chief Justice Altamas Kabir and Justices Vikramjit Sen and Anil Dave ruled: “The role assigned to the MCI under Sections 10A and 19A (1) of the 1956 Act vindicates such a conclusion. As an offshoot, we have no hesitation in holding that the Medical Council of India is not empowered to actually conduct the NEET.”

The MCI general body has now recommended to the government that it should be empowered to prescribe such a test — whether it is conducted by the National Board of Examinations, like in the case of NEET, or some other body is a call that can be taken later.

Students seeking admission to medical colleges — at both undergraduate and postgraduate levels — often need to criss-cross the country, appearing for numerous entrance tests. Sometimes, they allegedly have to pay huge sums as capitation fee. A common entrance test has been a long-standing demand of students, but has been opposed by private and minority institutes as well as some state governments.

The NEET plan too faced opposition right from the start. The original plan was to implement it for the 2012-2013 session but it had to be delayed because of opposition from states. Giving in to their demands, the ministry agreed to conduct the test in six regional languages — Tamil, Marathi, Assamese, Bangla, Telugu and Gujarati — but private institutes still objected.

This time too, even as the ministry is in the process of seeking opinions from other ministries, sources said Tamil Nadu Chief Minister J Jayalalithaa has already written to Prime Minister Narendra Modi opposing any such move.

Wednesday, February 3, 2016

Health Ministry guidelines on Zika Virus Disease

The Ministry of Health and Family Welfare issued guidelines on the Zika virus disease, here. The text of the guidelines is as follows.
Zika virus disease is an emerging viral disease transmitted through the bite of an infected Aedes mosquito. This is the same mosquito that is known to transmit infections like dengue and chikungunya.  Zika virus was first identified in Uganda in 1947.
World Health Organization has reported 22 countries and territories in Americas1from where local transmission of Zika virus has been reported. Microcephaly in the newborn and other neurological syndromes (Guillain Barre Syndrome) have been found temporally associated with Zika virus infection. However, there are a number of genetic and other causes for microcephaly and neurological syndromes like Guillain Barre Syndrome.
Zika virus disease has the potential for further international spread given the wide geographical distribution of the mosquito vector, a lack of immunity among population in newly affected areas and the high volume of international travel. As of now, the disease has not been reported in India. However, the mosquito that transmits Zika virus, namely Aedes aegypti , that also transmits dengue virus,  is widely prevalent in India.
A majority of those infected with Zika virus disease either remain asymptomatic (up to 80%) or show mild symptoms of fever, rash, conjunctivitis, body ache, joint pains. Zika virus infection should be suspected in patients reporting with acute onset of fever, maculo-papular rash and arthralgia, among those individuals who travelled to areas with ongoing transmission during the two weeks preceding the onset of illness.
Based on the available information of previous outbreaks, severe forms of disease requiring hospitalization is uncommon and fatalities are rare. There is no vaccine or drug available to prevent/ treat Zika virus disease at present.
World Health Organization has declared Zika virus disease to be a Public Health Emergency of International Concern (PHEIC) on 1st February, 2016.
[1] Zika virus disease has been reported so far in the following countries; Brazil, Barbados, Bolivia, Columbia, Dominican Republic, Equador, El Salvador, French Guyana. Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Puerto Rico, St Martin, Suriname, Virgin Island  and Venezuela. It may be noted   that this list is likely to change with time. Hence, updated information should be checked periodically.
In the light of the current disease trend, and its possible association with adverse pregnancy outcomes, the Directorate General of Health Services, Ministry of Health and Family Welfare advises on the following:
  1. Enhanced Surveillance
1.1.      Community based Surveillance
  • Integrated Disease Surveillance Programme (IDSP) through its community and hospital based data gathering mechanism would track clustering of acute febrile illness   and seek  primary case, if any,  among those who travelled to areas with ongoing transmission in the 2 weeks preceding the onset of illness.
  • IDSP would also advise its State and District level units to look for clustering of cases of microcephaly among newborns and reporting of Gullian Barre Syndrome.
  • The Maternal and Child Health Division (under NHM) would also advise its field units to look for clustering of cases of microcephaly among new borns.
1.2       International Airports/ Ports
  • All the International Airports / Ports will display billboards/ signage providing information to travelers on Zika virus disease and to report to Custom authorities if they are returning from affected countries and suffering from febrile illness.
  • The Airport / Port Health Organization (APHO / PHO) would have quarantine / isolation facility in identified Airports.
  • Directorate General of Civil Aviation, Ministry of Civil Aviation  will be asked to instruct all international airlines to follow the recommended aircraft disinsection guidelines
  • The APHOs shall circulate guidelines for aircraft disinsection (as per International Health Regulations) to all the international airlines and monitor appropriate vector control measures with the assistance from NVBDCP in airport premises and in the defined perimeter.
1.3    Rapid Response Teams
  • Rapid Response Teams (RRTs) shall be activated at Central and State surveillance units. Each team would comprise an epidemiologist / public health specialist, microbiologist and a medical / paediatric specialist and other experts (entomologist  etc) to travel at short notice  to investigate suspected outbreak.
  • National Centre for Disease Control (NCDC), Delhi would be the nodal agency for investigation of outbreak in any part of the country.
1.4       Laboratory Diagnosis
  • NCDC, Delhi and National Institute of Virology (NIV), Pune, have the capacity to provide laboratory diagnosis of Zika virus disease in acute febrile stage. These two institutions would be the apex laboratories to support the outbreak investigation and for confirmation of laboratory diagnosis.  Ten additional laboratories  would be strengthened by ICMR to expand the scope of laboratory diagnosis.
  • RT- PCR test would remain the standard test. As of now there is no commercially available test for Zika virus disease. Serological tests are not recommended.
  1. Risk Communication
  • The States/ UT Administrations would create increased awareness among clinicians including obstetricians, paediatricians and neurologists about Zika virus disease and its possible link with adverse pregnancy outcome (foetal loss, microcephaly etc). There should be enhanced vigilance to take note of travel history to the affected countries in the preceding two weeks.
  • The public needs to be reassured that there is no cause for undue concern. The Central/ State Government shall take all necessary steps to address the challenge of this infection working closely with technical institutions, professionals and global health partners.
  1. Vector Control
  • There would be enhanced integrated vector management. The measures undertaken for control of dengue/ dengue hemorrhagic fever will be further augmented. The guidelines for the integrated vector control will stress on vector surveillance (both for adult and larvae), vector management through environmental modification/ manipulation; personal protection, biological and chemical control at household, community and institutional levels. Details are at Annexure-I.
  • States where dengue transmission is going on currently due to conducive weather conditions (Kerala, Tamil Nadu etc) should ensure extra vigil.
  1. Travel Advisory
  • Non-essential travel to the affected countries to be deferred/ cancelled2.
  • Pregnant women or women who are trying to become pregnant should defer/ cancel their travel to the affected areas.
  • All travelers to the affected countries/ areas should strictly follow individual protective measures, especially during day time, to prevent mosquito bites (use of mosquito repellant cream, electronic mosquito repellants, use of bed nets, and dress that appropriately covers most of the body parts).
  • Persons with co-morbid conditions (diabetes, hypertension, chronic respiratory illness, Immune disorders etc) should seek advice from the nearest health facility, prior to travel to an affected country.
  • Travelers having febrile illness within two weeks of return from an affected country should report to the nearest health facility.
  • Pregnant women who have travelled to areas with Zika virus transmission should mention about their travel during ante-natal visits in order to be assessed and monitored appropriately.
  1. Non-Governmental Organizations
  • Ministry of Health &FW / State Health Departments would work closely with Non-Governmental organizations such as Indian / State Medical Associations, Professional bodies etc to sensitize clinicians both in Government and private sector about Zika virus disease.
 Based on available evidence, World Health Organization  is not recommending any  travel or trade restrictions.
  1.  Co-ordination with International Agencies
  • National Centre for Disease Control, Delhi, the Focal Point for International Health Regulations (IHR), would seek/ share information with the IHR focal points of the affected countries and be in constant touch with World Health Organization for updates on the evolving epidemic.
  1.  Research
  • Indian Council of Medical Research would identify the research priorities and take appropriate action.
  1.  Monitoring
  • The situation would be monitored by the Joint Monitoring group under Director General of Health Services on regular basis. The guidelines will be updated from time to time as the emerging situation demands.

DMER moves to abolish Brit era poison practice

Docs, irate about having to check murder accused Indrani Mukerjea's food for poison, had written against 'obsolete' rule; alternatives being considered

While the sordid case of Mumbai socialite Indrani Mukerjea last year —in which she was accused of having killed her own daughter Sheena Bora — created a flurry in social, political and law-enforcement circles, an offshoot of the consequences has served up a bitter pill to the medical fraternity as well.

Doctors, who were made to taste food for poison before it was served to Mukerjea in accordance with an archaic practice, while she was being treated at the J J Hospital after her arrest, had been very displeased and submitted a letter of protest to the Directorate of Medical Education and Research (DMER) late in 2015.

Now, a few months down the line, DMER has taken cognisance of the missive, saying it is working on an alternative method to do away with this practice that puts lives of resident doctors at threat for VVIPs.

Dr Sagar Mundada, state president of the Maharashtra Association of Resident Doctors (MARD), said, "This is a pre-Independence practice. The job is not for doctors — our work is to treat patients, for which we have a specialised education. It is good that DMER has taken note of this and is working towards abolishing the practice. In case of a murder accused, it is as if more importance is being given to the life of a criminal rather than a dignified professional."

Dr Pravin Shingare, DMER director, told Mirror, "The practice has been going on for decades and cannot be done away with immediately. We got a letter from the MARD asking us to abolish it. Now, we are working with them to implement an alternative in place of this, where a doctor will not have to taste food to detect poison for a VIP." A proposal in this regard is to be sent to the state health ministry soon.

Mukerjea had been admitted to the hospital for a suspected overdose in October 2015, where a resident medical officer had to taste everything she ate. It was only after 10 minutes, when it was established that there was to be no adverse reaction, that she was served the same food. The incident had left the doctors fuming and even considering approaching the state human rights commission.

Resident doctors or medical officers at government hospitals have had to taste food for VIPs for decades together now. In its letter, MARD called the practice obsolete and said they wish to do away with it as soon as possible. Interestingly, doctors are suggesting that instead of making them taste the food, a food inspector from the Food and Drug Administration (FDA) could be appointed to do the same, or advances in science could be used to ensure food safety in a less personal manner.

Shingare added, "The practice has been listed in protocols since the British era. Doctors had never protested about this before, so it went on. Now that they have objected, it is being addressed. There is no question of serving food to VIPs and VVIPs without tasting, but we have to figure out who will do it."

Speaking to Mirror on condition of anonymity, a doctor, who has had to follow this practice, said, "It is very demeaning. We are not guinea pigs for VIPs. Our work is to treat them, for which we are well educated. You can't be treated without respect just because you don't have as much money or power."

DMER's move was hailed by Dr Kanharam Patel, president of MARD's Pune Chapter, who said, "We are not subjects to conduct trial and error on. We have always been against this practice."

Dr Avinash Bhutkar, president of the Indian Medical Association (IMA) Pune, said, "This is discrimination between two humans — one is dispensable and the other is indispensable. Moreover, some poisons may have a delayed effect, making this practice technically pointless. Doctors are not food experts to taste whether something is not right. They should put some other mechanisms in place instead of this."

WHO certifies India as free of neo-natal tetanus, says Nadda

The World Health Organisation (WHO) has certified India as free of neo-natal tetanus, said Union Health and Family Welfare Minister J.P. Nadda, adding the country is poised to reach immunisation cover to 90 percent soon.
"Kilkari launched for better awareness among pregnant women, parents of children and field workers. As many as 1.18 crore pregnant women registered in Mother Child Tracking System during 2015-16 (till Oct'), while the ministry has adopted a life cycle and continuum of care approach for neonatal, child and maternal healthcare," he said while speaking at the All India Regional Editors Conference here on Tuesday.
Lauding the Centre's 'Mission Indradhanush' programme, he said as many as 35 lakh children had been given total immunisation in one year, while 20 lakh children had been given total immunisation during the first phase of this mission.
"The mission, which has resulted in spreading immunisation cover to end preventable deaths, aims to cover all left out and missed out children for full immunisation through seven vaccines, as we implement world's largest immunisation programme," he said, adding that four new vaccines have been added.
Stating that the shortage of manpower and paramedics are challenges which the health sector faces, Nadda said, "The first challenge the health sector faces is the availability of services, which is more serious in urban areas. At least 70 percent of healthcare is given by private sector, whose focus is tertiary sector, which is resulting in the shortage in primary healthcare."
Pointing out that 60 percent of disease-related deaths are due to non-communicable diseases, while 60 percent of deaths are attributed to non-communicable diseases, he said that his ministry was focussing on these in addition to communicable diseases.
He said under 'e-hospital Yojana', OPD (Outpatient Department) registration has been made online in the All India Institute of Medical Sciences, Ram Manohar Lohia Hospital, Safdarjang Hospital and Postgraduate Institute of Medical Education and Research (PGIMER).
"As many as 70 medical colleges to be converted into Super Specialty Hospitals, while 58 district hospitals are being converted into medical colleges, and the Centre would lay more focus on preventive healthcare," said Nadda elaborating on the government's vision for healthcare.