Medical Education and Research in India

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Talking about Medical Council of India (MCI) means talking about medical education and health status of the country, the past, present, and possibly future. The sixty-year-old organization is described in the Parliamentary standing Committee (PSC) report as ‘CLUB of influential medical professionals who act without any fear of governance and regulations’. The Medical Council of India (MCI) which was established by the British became a statutory body in 1956 after independence ‘with the responsibility of establishing and maintaining high standards of medical education and recognition of medical qualifications in India. It registers doctors to practice in India, in order to protect and promote the health and safety of the public by ensuring proper standards and ethics in the practice of medicine’. The act under which the council functions is given a blanket protection: ‘No act done by the Council shall be questioned on the ground merely of the existence of any vacancy in, or any defect in the constitution of the Council’. All actions of MCI continued unquestioned, almost in an autocratic style for several decades. As  may be the case with any regulatory body, MCI has all evils of corruption, nepotism, and personal advantages.

 

Sometimes even an average mind starts thinking that health education and health care planning, do go hand in hand. It is a matter of shame when the twelfth Five Year Plan report says nearly one million Indians die every year due to inadequate health care facilities. There is something wrong that affects the health care system at roots. Another observation which is equally painful is that about 700 million Indians have no access to specialist care and 80% of specialists are working in urban areas. Does the regulatory body, the MCI ever have sensitively responded to the country’s health needs?  With over 380 medical colleges, and around 9.25 lac doctors on MCI records, the shortage of doctors is a perennial topic of discussion by our custodians of health. Let us have a look at the distribution of medical colleges whether state-run or private: Five states (Karnataka, Tamilnadu, AndhraPradesh, Telangana, Maharashtra) dominate with nearly 50% seats at MBBS level. These states account for only 30% of the country’s population. This kind of imbalance leads to non-availability of doctors at various places of need. The parliamentary committee further noted that ‘registration and approvals of colleges and courses by MCI is ridden with corruption and graft. There is poor regulation of graduate and post-graduate education. There is a shortage of quality teachers’.

 

It is a painful fact that until 1983 India had no formal health care policy. Public health had been on low priority in successive five-year plans. The MCI that has been in vogue right from independence days seems to have served no purpose with no specific plans or directions for health care. Hence, MCI by default started growing with built-in anomalies.  The main mandate of MCI is to provide precious professional human resources to take care of the health of the people. It is, therefore, important that the course and training should be relevant and need to be based. It is equally important to expose the students to modern technology and impart skills of international standards. Hence, medical education cannot be insensitive to the needs of the country.

 

The edifice of Indian health care as per the 1983 National Health Policy stressed rural, primary, and preventive centered health care approach compared to urban-centered curative approach. The recommendations of the committee included strong preventive services and a decentralized system of health care, all at low cost with community participation. The policy on the face of it is laudable but failed to reach expectations because of poor infrastructure and low attendance of medical staff, and grossly inadequate drug supply. Any program is bound to fail if the authorities do not see the three important aspects namely, Planning, Execution, and Monitoring components if they are not structured and integrated properly. It is unfortunate Health falls under state subject with Central involvement in design and implementation of national programs like malaria, filarial eradication etc. Central and State functions and division of administrative roles are blurred and are successful to a very limited extent. 

 

In 1990 the Indian health sector underwent an irreversible change possibly which ushered the perils more than welfare. This is allowing the private agencies to take care of secondary and tertiary care endangering the government’s responsibility limiting itself to Primary health to a large extent. In 2002 , there was an apparent realization ‘increase utilization of public health facilities from the current level of less than 20% of more than 75%’ but indicated no measurable actions in this regard. The whole report remained as an academic exercise. The National Rural Health Mission with a large corpus was launched in 2005 and later expanded to include urban as well. The mission had witnessed non-utilization or mal-utilization of funds. The point of consideration is the availability of human resources from medical to non-medical. MCI which is primarily concerned with providing qualitative, knowledgeable and skilled doctors to man the health care, has miserably failed. About the good, bad and ugly of private health care services is a totally a different area that deserves discussion separately. 

 

One can imagine the irregularities of malignant proportion committed by MCI in the long history of its existence that necessitated Supreme Court not only to point out but also to come out with a decision of appointing an overview committee. What made the Supreme Court react so sharply and decisively?

 

The apex body MCI is so powerful in making an amendment exempting ‘Professional associations of doctors’ from the ambit of MCI medical code of ethics regulations (2002) in last February to which the Government ’meekly’ succumbed, acceding to this  nefarious amendment. The Parliamentary Committee said ‘exempting professional association of doctors from the ambit of Ethics Regulations is nothing short of legitimizing doctors associations indulging in unethical and corrupt practices by way of receiving gifts in cash or kind under any pretext from the pharmaceutical industry or allied health industry’. These remarks are extremely derogatory and speak of the image of the profession in the eyes of the public. Further, the high-powered Parliamentary Committee added, ‘It seems the MCI has become captive to private commercial interests, rather than its integrity in public interest’.

 

The PSC report   narrates the painful outcome of this MCI amendment “the effect is evident as 63 million people are faced with poverty every year due to health care costs alone which indicate health care is moving away from the reach of the people in general and the poor in particular’. Some of the states which have launched Arogysri to provide tertiary carefree to the poor have only helped some private hospitals to live with false records, though a few people are genuinely helped. This issue needs attention in detail.

 

The composition of MCI has also come under scanner by the PSC.  The report noted: ‘The MCI as presently elected, neither represents professional excellence nor its ethos. The current composition of the council reflects that more than half the members are either from 21 corporate hospitals or in private practice’. Recently I read a news report that an advisory committee for a Health University, are all from the corporate sector who never taught a single student in their lifetime with a bureaucrat as the Chairman. Anyway, medical education is undoubtedly in peril. Since money power plays an important role in its (MCI)elections, it should not be an elected body dominated by vested interests but should represent all stakeholders, says the PSC report. A shocking observation has been made that in spite of  over 22 medical faculties from Government sector, certain ‘serial inspectors’ were part of almost half the inspections conducted in the year 2014 and of the 261 inspections done in the same year. The black mark on the MCI reached its peak with the arrest of its President for massive unprecedented corruption.

 

The Health Ministry owes an explanation to the country for allowing the shady corrupt organization to function for decades, going scot-free despite many complaints. The public is compelled to think that Governments and the MCI are hands in glove for the decades of misconduct.

 

Let us briefly look at the responsibility of the MCI towards academics in the area of medical sciences. Even our primary, secondary and higher education is constantly reviewed by the Governments and NCERT. Where is such accountability for MCI? It is sad to note that MBBS syllabus remained unchanged for 14 years when medical sciences and technology grew exponentially. Methods of teaching hardly changed for decades.

 

What is the need of the hour to save the face of the MCI, and medical education in India? The institution of MCI possibly needs to be abolished. Any change without accountability would only be cosmetic in nature. As suggested, National Medical Commission may be a good alternative but with firm guidelines. There should be strong coordination between medical education and the country’s health needs. Medical college inspections, infrastructure requirements, and appointment of staff need specific guidelines with academic experts  of repute and integrity. The syllabus and methods of teaching should be reviewed by a core committee. Other suggestions made by the expert committee (PSC) are relevant and require serious consideration.

 

Medical Research:

 

Medical education and Research are inseparable components of health care. As is often said, the purpose of education is to develop  a questioning mind. Without going into the general scenario of education and research in science as a whole, let us ponder over the current status of medical research in India. In the postgraduate curriculum, submission of thesis /dissertation has been mandated before qualifying for the specialty by MCI. Though ritualistic in nature for many, it has been a good initiative, as some entered into the field of medical research. 

 

When one speaks of quality in practice, it envisages that the specialists are current and relevant. This is possible only through constant upgrading of knowledge and skills. This habit automatically ignites the probing mind and provides the motivation to enter into research. Broadly, in the medical field, the focus of research could be on Public Health, Applied Medical Research or Basic Sciences. 
Public health research is of paramount importance to countries like India as it provides information regarding the public health status, changing patterns in disease prevalence, and more importantly, the impact of several health programs initiated by the Government. No national project can be considered useful unless we have the data regarding its performance and results. However, public health research in India is slow. I am told that public health reports are available but have not become the basis for research papers because of which scientists are unable to learn about the progress or problems.

 

Medical institutions that impart education, both at undergraduate and postgraduate levels are supposed to be role models of knowledge and research.  More than half a dozen Central Government agencies fund institutional research. Since 1949, Indian Council of Medical Research has been functioning as the nodal agency for medical research. The different task forces constituted to address various health problems of the country working under ICMR could not create enough impact on health research. The Department of Health Research has been established in 2007 through a Presidential order under the Ministry of Health Family Welfare and is yet to make its presence felt by research scientists. The health research funding underwent several modifications especially in funding patterns, Industry versus Governmental. 

 

There is not enough support for research by non-governmental institutes. Apart from this, the priority given to central institutes is  a reflection of the attitude of funding agencies. However, on the publications front, research made by certain Indian medical Institutions is laudable. In a recent medical research report that four Indian Institutes are among the top ten that have published in peer-reviewed journals, namely All India Institute of Medical Sciences, New Delhi, PGI Chandigarh, CMC Vellore and Sanjay Gandhi Institute of Medical Sciences, Lucknow. Unfortunately, a large number of medical colleges have shown dismal performance. "What's most shocking is that 332 (57.3 percent) medical colleges had not a single publication during this period. The states with the largest number of private medical colleges did the worst, with more than 90 percent of the medical colleges in Karnataka and Kerala having no publication at all,” says Dr Simaran Nundy, Dean of Sir Gangaram Hospital, Delhi.  One of the factors for such poor performance by both, private and state-run institutions, is that there is no weight age for research in promotions, except seniority. Further, many Institutions have the Deans and Directors with hardly any research interests.

 

"To bring medical education across states at par, India needs to incentivize quality research, which is an indicator of an institute's quality of education and clinical care. Research doesn't affect promotions but is based on seniority and clinical practice. With doctors running private clinics in many medical colleges in their free time, research suffers," said the President of Public Health Foundation of India, Dr. K Srinath Reddy. Research minds are important irrespective of where they are located, public or private sector. Support of Government is inevitable for sustainable growth and presence.

 

Dr K.S.Ratnakar

 

(The author is Former Dean of NIMS and currently, Director, Global Medical Education and Research Foundation, Global Hospitals, Hyderabad)