Who should regulate doctors?

Guest article by Sanjeev Sanyal

It is now widely accepted that India’s medical sector needs a new regulatory regime. Several studies have found glaring lapses in the functioning of the existing system under the Medical Council of India (MCI). The current system is arguably beyond repair and a committee headed by NITI Aayog vice-chairman Arvind Panagariya has proposed to replace it with a new body called the National Medical Commission (NMC). A draft of the enabling legislation has been circulated for comments.

In many ways the proposed institution will be a big improvement on the existing arrangement. The MCI is an unwieldy institution with 102 members — 35 nominated, 67 elected — who keep churning. In contrast, NMC will have just 20 members including the chairman, amember-secretary, eight ex-officio members and 10 part-time members.

Moreover, the NMC will be backed by a permanent secretariat staffed by professionals. So, the new institution will be leaner but also have institutional memory.

The draft Bill further proposes four semi-autonomous boards that will function under the NMC to deal with the following specific issues: undergraduate education, post-graduate education, rating of institutions and regulation of the medical profession.

Importantly, a live national register of all medical practitioners in the country will be created. Broadly speaking, the new architecture would be a big improvement on the opaque and archaic system that exists today. Nonetheless, there are some areas where it could be improved.

First, the proposed reforms are mainly directed at improving the quality of education, standardising college entrance tests and upgrading curricula. These are obviously important, but perhaps it is excessive that three of the four semi-autonomous boards are dedicated to medical education. The task of the NMC is to regulate the medical sector more broadly and other areas need equal attention.

First, the good news

For instance, there is relatively little emphasis on consumer rights, malpractice and unethical behaviour. As anyone using the Indian medical system knows, the system is plagued by needless tests, opaque pricing, unnecessary surgeries and fake drugs.

Admittedly, one of the four statutory boards is supposed to regulate the profession. But it appears to have been given limited firepower. At most, it is expected to apply a still undefined ‘code of conduct’ on individual doctors. This will almost certainly be inadequate to deal with a complex ecosystem consisting of hospitals, clinics, pathology labs, nursing staff, insurance, pharmaceutical companies and so on.

The second issue is the composition of the NMC and the statutory boards. The proposed reform will bring some diversity of membership, but the majority is still likely to be doctors. This is a recipe for conflict of interest and was one of the major problems with MCI.

As a note prepared by the National Institute of Public Finance and Policy (NIPFP) puts it, “The NMC, although diverse, comprises a majority of doctors. The statutory boards comprise solely of doctors. This is likely to lead to a situation of regulatory capture by the regulated entity.”

The NIPFP note proposes that “the NMC should include a majority of members from diverse backgrounds while providing for representation from doctors. The Bill should lay down detailed eligibility criteria for members who are not medical professionals.”

While I agree with NIPFP on the risk of regulatory capture, I do not think the Bill precludes the appointment of non-doctors such as lawyers and public health experts to the boards. The problem is that the paucity of technically proficient non-doctors will mean that doctors will dominate in practice.

My view is that non-doctors are not really needed on the boards related to education and curriculum. However, non-doctors should be included on the board related to regulating the profession and perhaps even be in majority. By concentrating nondoctors in the role of regulating the profession, the NMC will make best use of the tiny pool of non-doctors who have the expertise to operate in this highly technical field.

The third lacuna in the proposed Bill is that there is no explicit mention of who supervises research, field trials, introduction of new drugs/technology, and so on. Managing the medical sector cannot just be about teaching existing knowledge but also about generating and absorbing new knowledge. The excessive emphasis on teaching over research and testing is a problem that plagues all technical fields in India.

The NMC is potentially a big improvement on the existing system. Nonetheless, I hope the above concerns will be addressed in the version of the Bill expected to be introduced in Parliament in the winter session. Ihave one further suggestion. The permanent secretariat of the new institution should not be in either Delhi or Mumbai as they are already home to many national bodies. These cities cannot be avoided for institutions dealing with areas such as foreign policy or finance, but the NMC can be established in any city with reasonable connectivity such as Bhopal, Bhubaneswar or Jaipur.

Let me give in to my linguistic bias and also suggest Kolkata. It may have declined in other fields but still retains a significant medical cluster. Besides, it would tickle the inner hypochondriac that lives within every Bengali.

DISCLAIMER : Views expressed above are the author's own.