Thanks to the Ketan Desai episode, we are at a point pregnant with possibilities for reform in the practice of, and education in, the health professions. The most fundamental human right is the right to life. And that is an empty phrase without health and health care. In this basic area of human welfare, we are still far from our “tryst with destiny”. Many respected commissions have produced well-thought-out recommendations on how this distance may be covered, beginning with the Bhore Committee Report in 1946, but all in vain.
Hence the importance of seizing this moment for a clean-up. But, reforms towards efficiency and rectitude alone will not suffice. That is because, in a democracy committed to inclusive and speedy development, the challenge of regulation of the health professions is quite different from that in 1933, when the first Act in this regard established a pattern that has changed little. We now have an opportunity to rethink the very nature of “regulation” in this field.
There are four major elements in the regulation of health professions. The element that attracts most public attention is the gatekeeper function of health councils, i.e., oversight of the qualifications that allow entry into the professions. Impropriety in the establishment of, and admissions to, health education institutions is a flashpoint in the public perception. But in reality it affects the rights of only a tiny segment of society. Even with all conceivable expansion of the health professions, there will never be room in them for even one per cent of India’s population. The proposed reform needs to address more than this emotive component of regulation.
The public is familiar with the second element of regulation — enforcing accountability — but by its total failure. This involves the disciplining of errant behaviour by professionals, particularly in regard to competence and conscientiousness. The health professions have traditionally been allowed (as in the present Acts) to be their own watchdogs. In practice, these watchdogs do not even bark — let alone bite — except in their own interests. Thus this has been a failure of self-regulation. The public will eagerly hope that the present moment will be seized to set right the mechanism for disciplining health professionals.
In the health professions, education and eventual practice are uniquely bound to each other. And a separation of the regulation of these two is better avoided. Indeed, it is this linkage that legitimises a leading role for the Central government in this field, though health care delivery rests primarily with the states. This would mean that the proposed new National Council should have a wider mandate than just facilitating human resources in health. Nor can the proposed National Commission for Higher Education and Research be the appropriate regulatory body in this field.
The third element of regulation is the enforcement of uniform standards of education and admission in the profession. This is the only stipulated function of the Medical Council of India (MCI). It has preoccupied itself mainly with prescribing curricula, examinations, clinical facilities and infrastructure, all in line with Western practices based on some unquestioned assumptions. In most other countries they first decide the kind of medical graduate that best serves their national need (as the Bhore Committee did) and then fashion medical education accordingly. The mandate of the new council must be first to define the kind of health professionals who will take us closer to universal health coverage, and then to maintain educational standards appropriate to that.
That leads us to the most neglected and yet important dimension of regulatory authorities. All professions have their own internal logic and standards and these need to be nurtured for their sustainability and progress. And autonomous professional regulatory bodies may seem best suited to that. But the societal goal of promoting universal access to basic health care was not spelt out in their enabling Acts. Nor have the councils themselves embraced such societal objectives as guiding principles in their regulatory role. So their major activities have been strictly related to their professions, such as increasing the output of graduates, multiplying sub-specialities and ensuring the standing of their graduates in the world market.
Not surprisingly, these have not delivered proportionate benefits in health conditions. Our basic unmet need is universal access to essential health care. What would it profit the country even if we have a million doctors from a thousand medical colleges and all of them are fit to succeed in any branch of medicine any where in the world, if most of them are not found where most people live in India and in any case are not trained in the attitudes and skills necessary to address the people’s basic health needs? Therefore, the most urgent reform required in the health professions is to articulate the overriding societal goals in this field and then to facilitate a partnership of all the health professions towards that goal.
What are the practical implications of such an approach? It would be good to have one central regulatory authority for all the health professions together. But it must be more than just a human resource agency. Its role must be to promote training and practice in the health professions around national interests in this field and to promote the individual professions in this larger context and towards larger goals. This would naturally mean that membership of the regulatory body cannot be confined to health professionals but must include all stakeholders in health care and promotion of health, especially advocates of patients’ concerns and advocates of a holistic understanding of health and health care delivery. A tripartite composition with equal weightage between the ministry of health, the health professions and the watchdogs of the people’s concerns in health might provide the required checks and balances.
The mechanisms and processes of this new regulatory structure and whether these may still retain a degree of autonomy with social accountability would bear separate scrutiny. The Ketan Desai episode has brought us to the cusp of a thorough reform of the regulation of our health care professions. The historic possibilities offered by this turn of events will be missed if we do not seize this moment to fashion a regulatory structure for the health professions permeated by societal needs and in which society at large also has its say.
The author was formerly on the faculty of the Christian Medical College, Vellore
