AIIMS, PGI docs to be mentors, provide super-speciality care in six new AIIMS

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Top specialists from AIIMS, New Delhi, will soon be seen providing medical care and guidance to research wings (centre) at six new AIIMS.
The Union ministry of health and family welfare (MoHFW) has decided to provide impetus to hospitals and research in six new medical institutes modelled on the lines of AIIMS, New Delhi.

To begin with, the head of cardio thoracic and vascular surgery (CTVS) centre of AIIMS, New Delhi, Professor Dr Balram Airan will now mentor cardiology units in six new AIIMS dotted across the country – Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur and Rishikesh.

“We are in the process of identifying more specialists from AIIMS, New Delhi, and PGIs who would assist in six new AIIMS as mentors. There would be sharing of best practices, knowledge and develop a vibrant interlink,” said Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) joint secretary, Sunil Sharma. Neurology, oncology, trauma and emergency care among other specialists are likely to follow Dr Airan’s footsteps.

Six years after these institutes were set up hospital services are yet to be at par with local tertiary care hospitals.

Specialists will not only provide guidance in research and development, but also demonstrate medical procedures, which would benefit patients, he added.

“Doctors from the new institutes will also benefit from visiting faculty of AIIMS, New Delhi. Some of the doctors have been associated with specialists from AIIMS, New Delhi in the past,” said AIIMS, Raipur, director, Dr Nitin Nagarkar.

He also holds the dual charge of AIIMS, Bhopal, where the cardiology unit is headed by assistant professor Dr Gaurav Khandelwal and cardiothoracic surgery is headed by assistant professor Dr Yogesh Kumar Niwariya.

 “It would not be restricted to clinical specialists,” he said.
Since 2012, over a dozen specialists, who had joined AIIMS, Bhopal, later resigned from the institute. Lack of infrastructure and delay was cited as one of the primary reasons.

Currently, each of the six new AIIMS has an estimated 400 plus hospital bed and post-graduate courses in various departments.

NBE files police complaint over charges of fraud in NEET-PG

The National Board of Examinations declared the result of NEET-PG 2018 on 23 January for the 128,917 candidates who had appeared in the exam. Photo: HT

The National Board of Examinations (NBE), an autonomous body under the health and family welfare ministry, has filed a police complaint over charges of fraud in the National Eligibility and Entrance Test (NEET) for studying medicine, taking the allegations “very seriously”.

NBE received complaints that touts or agents are luring and misleading candidates for medical schools promising them good marks, even a merit position, in the NEET-PG exams for a payment.

The NBE filed a complained with the cyber cell and crime branch of Delhi Police on Saturday.

“NBE has taken this very seriously and has filed a complaint with the local Police, Cyber Cell and Crime Branch of Delhi Police. Candidates are cautioned not to be misled by any such false and bogus claims,” said a statement issued by the Union health ministry on Saturday.

“It is clarified that NBE does not make any phone calls to any candidate or issues any communication regarding the change of rank obtained in any of the exams conducted by NBE or for any other such thing which is against the provisions of law,” it added.

NBE declared the result of NEET-PG 2018 on 23 January for the 128,917 candidates who had appeared in the exam.

Marks are provided for each candidate. If candidates have same marks and the same number of correct answers in NEET-PG 2018, the winning candidates will be announced on the basis of marks obtained in the MBBS professional exams.

Due to some candidates making incorrect entries for their MBBS marks in the online application form, NBE has given all applicants a one-time final chance to make corrections in their MBBS marks through the online portal. They have to submit their scanned MBBS mark sheets as proof.

“Tie-breaking and generation of the merit list shall be done thereafter in accordance with the criteria mentioned in the Information Bulletin. As per NBE Public Notice dated 29/01/2018.

“The merit list shall be declared by 15 February 2018. NBE shall also publish the number of questions attempted correctly and incorrectly by the candidates at the time of declaration of the merit list,” said the government statement.

NEET-PG merit list on Feb 15

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The National Board of Examination (NBE) today said it would publish the merit list of NEET post-graduate examination 2018 on February 15 under new rules for addressing tie-breaking issues.The board, an autonomous body under the Ministry of Health, also warned students against touts and agents, saying it had filed an FIR with the Delhi Police on certain complaints about people promising improved merit and marks to aspirants in lieu of money.The board said in cases of a tie-breaker between students, marks of MBBS professional exam would be taken into consideration instead of the date of birth which used to be the case previously. The NBE today said: “We have received complaints that tout and agents are alluring candidates to help them secure good merit position and marks if money is paid to them. The NBE has taken this very seriously and filed a complaint with the local police, cyber cell and crime branch of the Delhi Police. Candidates are cautioned not to be misled by false claims. NBE does not call any candidate or issue any communication regarding the change of rank obtained in any of the exams conducted by NBE or for any other such thing which is against the law.”The NBE had conducted NEET-PG 2018 on January 7 for admission to MD/MS/PG diploma courses. NEET-PG 2018 was conducted on a computer-based platform in 150 cities in a single session format.The NBE had declared the result of NEET-PG 2018 on January 23. “In the result, NBE provided the marks obtained by each candidate. Tie-breaking of candidates having same marks and same number of correct responses in NEET-PG 2018 will be done on the basis of marks obtained in the MBBS professional exams.

NEET PG Results 2018 Declared @ Nbe.edu.in; Check Now

NEET PG Results 2018 Declared @ Nbe.edu.in; Check Now

National Board of Examinations (NBE) has declared the NEET- PG 2018 results on the official website of the board. The result of NEET-PG 2018 indicating the score obtained by the candidates has been declared and can be seen at NBE website nbe.edu.in. According to NBE, the merit position of the candidates will be declared in due course after applying the tie-breaker criteria as given in the information bulletin for NEET-PG 2018. Earlier, the NBE had allayed certain false or bogus claims which were being made to some applicant NEET-PG 2018 candidates regarding securing a rank in NEET-PG 2018.

“It is hereby clarified that the result of NEET-PG 2018 shall be declared by NBE solely on the basis of performance of the candidates on the examination day,” it said then.

It also told candidates to not to get misled by any false or bogus claims regarding obtaining a rank in NEET-PG 2018.

“The allotment of PG seats pursuant to declaration of NEET-PG 2018 result shall be done by respective government authority as indicated in the Information Bulletin,” it said.

NEET PG 2018 Results: How to check

Follow these steps to check your NEET PG 2018 results:

Step One: Go to the official website of NBE, which hosts NEET PG results, nbe.edu.in
Step Two: Click on the NEET PG link
Step Three:Login with your registration details
Step Four: Click submit

Step Five: Download your results and score card

The score card of the candidates who appeared in NEET-PG 2018 can be downloaded from NEET-PG web site nbe.edu.in. Score card will not be sent individually to the candidates. Candidates are requested to download their score cards from web site nbe.edu.in.

NEET PG Results 2018: Cut-Off Details

Check the NEET 2018 results cutoff details here:

neet pg cutoff, NEET PG 2018 results, nbe.edu.in. nbe edu in, www.nbe.edu.in, neet pg results cutoff, neet pg, neet pg results,nbe result, nbe website, neetpg result, neet pg 2018 result,

The NEET PG results notification has said the candidature is purely provisional subject to fulfillment of eligibility criteria as mentioned in exam information bulletin.

Capacity building for primary health care

A pluralistic and integrated medical system remains a solution worth exploring

A contentious element of the National Medical Commission (NMC) Bill 2017 — an attempt to revamp the medical education system in India to ensure an adequate supply of quality medical professionals — has been Section 49, Subsection 4 that proposes a joint sitting of the Commission, the Central Council of Homoeopathy and the Central Council of Indian Medicine. This sitting, referred to in Subsection 1, may “decide on approving specific bridge course that may be introduced for the practitioners of Homoeopathy and of Indian Systems of Medicine to enable them to prescribe such modern medicines at such level as may be prescribed.”

Missing the reality

The debates around this issue have been ranging from writing-off the ability of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners to cross-practise to highlighting current restrictions on allopathic practitioners from practising higher levels of caregiving. However, these debates miss the reality: which is a primary health system that is struggling with a below-par national physician-patient ratio (0.76 per 1,000 population, amongst the lowest in the world) due to a paucity of MBBS-trained primary-care physicians and the unwillingness of existing MBBS-trained physicians to serve remote/rural populations. Urban-rural disparities in physician availability in the face of an increasing burden of chronic diseases make health care in India both inequitable and expensive.

Therefore, there is an urgent need for a trained cadre to provide accessible primary-care services that cover minor ailments, health promotion services, risk screening for early disease detection and appropriate referral linkages, and ensure that people receive care at a community level when they need it.

Issue of cross-prescription

The issue of AYUSH cross-prescription has been a part of public health and policy discourse for over a decade, with the National Health Policy (NHP) 2017 calling for multi-dimensional mainstreaming of AYUSH physicians. There were 7.7 lakh registered AYUSH practitioners in 2016, according to National Health Profile 2017 data. Their current academic training also includes a conventional biomedical syllabus covering anatomy, physiology, pathology and biochemistry. Efforts to gather evidence on the capacity of licensed and bridge-trained AYUSH physicians to function as primary-care physicians have been under way in diverse field settings, and the call for a structured, capacity-building mechanism is merely the next logical step.

The 4th Common Review Mission Report 2010 of the National Health Mission reports the utilisation of AYUSH physicians as medical officers in primary health centres (PHCs) in Assam, Chhattisgarh, Maharashtra, Madhya Pradesh and Uttarakhand as a human resource rationalisation strategy. In some cases, it was noted that while the supply of AYUSH physicians was high, a lack of appropriate training in allopathic drug dispensation was a deterrent to their utilisation in primary-care settings. Similarly, the 2013 Shailaja Chandra report on the status of Indian medicine and folk healing, commissioned by the Ministry of Health and Family Welfare, noted several instances in States where National Rural Health Mission-recruited AYUSH physicians were the sole care providers in PHCs and called for the appropriate skilling of this cadre to meet the demand for acute and emergency care at the primary level.

Our own experience at the IKP Centre for Technologies in Public Health shows that there is hope. Here, the focus has been on deploying a capacity-building strategy using AYUSH physicians upskilled through a bridge-training programme, and the use of evidence-based protocols, supported by technology, to deliver quality, standardised primary health care to rural populations. Protocols cover minor acute ailments such as fever, upper respiratory tract infections, gastrointestinal conditions (diarrhoea, acidity), urological conditions, as well as proactive risk-screening. The Maharashtra government has led the way in implementing bridge training for capacity-building of licensed homoeopathy practitioners to cross-prescribe.

As anchors

Capacity-building of licensed AYUSH practitioners through bridge training to meet India’s primary care needs is only one of the multi-pronged efforts required to meet the objective of achieving universal health coverage set out in NHP 2017. Current capacity-building efforts include other non-MBBS personnel such as nurses, auxiliary nurse midwives and rural medical assistants, thereby creating a cadre of mid-level service providers as anchors for the provision of comprehensive primary-care services at the proposed health and wellness centres. Further, the existing practice of using AYUSH physicians as medical officers in guideline-based national health programmes, a location-specific availability of this cadre to ensure uninterrupted care provision in certain resource-limited settings, as well as their current academic training that has primed them for cross-disciplinary learning hold promise. These provide a sufficient basis to explore the proposal of bridging their training to “enable them to prescribe such modern medicines at such level as may be prescribed”.

Ensuing discussions will be well served to focus on substantive aspects of this solution: design and scope of the programme, implementation, monitoring and audit mechanisms, technology support, and the legal and regulatory framework. In the long run, a pluralistic and integrated medical system for India remains a solution worth exploring for both effective primary-care delivery and prevention of chronic and infectious diseases.

Aparna Manoharan and Rajiv Lochan are involved with the IKP Centre for Technologies in Public Health;Rajiv Lochan is MD and CEO ofThe Hindu Group

A pioneer in biotechnology

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Har Gobind Khorana is credited with making the first synthetic genes by cutting and pasting DNA bits

Who was Har Gobind Khorana?

Nobel Laureate Har Gobind Khorana’s contributions to biology are of contemporary relevance for some of the most exciting areas such as synthetic biology and gene editing. A Google Doodle on Tuesday to mark the 96th birth anniversary of the Indian-origin American scientist this week stoked much interest in his work.

What were his contributions to biology?

After James Watson and Francis Crick found that DNA (De-oxy ribonucleic acid) had a double-helix structure, Khorana was among those who significantly built on that knowledge and explained how this sequence of nucleic acids (better known as the genetic code) goes about making proteins, which is critical to the functioning of cells. The Nobel Prize in Physiology or Medicine for 1968 was awarded jointly to Robert W. Holley, Har Gobind Khorana and Marshall W. Nirenberg “for their interpretation of the genetic code and its function in protein synthesis.” Khorana was able to create nucleic acids in the lab and did so by figuring out the order in which nucleotides needed to be to make a suite of amino acids, which are the basic units of proteins.

Khorana is credited with making the first synthetic genes by cutting and pasting different bits of DNA together. This is considered a forerunner to the method called Polymerase Chain Reaction that is among the methods used to commercially read the unique genetic structures of organisms today. He further placed the lab-made gene in a living bacterium and was, in that sense, a founding father of biotechnology. The CRISPR/Cas9 system, which is the glitziest new toy in genetics and is used alter the functioning of certain genes, references the work of Khorana as a key influence.

What was his connection with India?

Khorana was born in 1922 in Raipur, a village in Punjab now part of Pakistan. He was the youngest of six siblings and his father was a ‘patwari’, a village agricultural taxation clerk in the British Indian system of government. He lived in India until 1945, when the award of a Government of India Fellowship made it possible for him to go to England for a PhD at the University of Liverpool. Khorana became a naturalised U.S. citizen in 1966.

System check

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It is high time the medical sector was regulated and made accountable

It is not about money,” says Rinku Singh. “I lost my father. But my mother gave her kidney for his treatment. And, I owe it to her to get some justice.” Rinku, 34, runs a mobile store in the Azamgarh district of Uttar Pradesh. For more than a year, he has been in a legal tussle with Max Super Speciality Hospital, Saket, Delhi, whom he has sued for negligence and inflated bills.

In 2015, Rinku’s father was advised a kidney transplant by doctors at AIIMS. “The waiting list for the procedure at AIIMS ran into several months. So we decided to seek treatment from a private hospital in Delhi,” he says. At the private hospital, the transplant was declared successful. But within hours of the surgery, Rinku claims his father complained of stomach ache and lay in pain with no doctor to attend to him. Rinku says there were several instances of medical negligence that resulted in his father’s death. “We found there were reports of another patient in my father’s case file. The night before the transplant surgery, the nurse forgot to give him an injection that would have helped his body accept the donated kidney,” he says.

Unconvinced by the explanation given to him by the doctors, Rinku approached several authorities including the Delhi Medical Council (DMC). “The DMC cleared the hospital of all charges. The DMC is biased towards the doctors,” he says. “The hospital may have denied the charges, but they have no documents to prove their side of the story. Now I am preparing to submit my case to the Medical Council of India. I am also fighting a case in the consumer court since 2016.”

These days, Rinku is also closely watching the debate over the case of Dwarka-based Jayant Singh, who lost one of his seven-year-old twins, Adya, to dengue in September. He was billed Rs 15.69 lakh for the treatment, which included costs for 1,600 pairs of gloves and 660 syringes, in the paediatric ICU of Fortis Memorial Research Institute in Gurugram. Jayant’s case attracted a lot of attention, following a tweet by his friend in November, and swung the state authorities and the Union ministry of health and family welfare into initiating an enquiry into the matter. A probe by the Haryana government found the hospital guilty of overcharging, and the hospital might lose its land lease. The National Pharmaceutical Pricing Authority also found that the hospital had made huge profits on consumables such as syringes. Jayant, an IT professional, has lodged an FIR, and hopes the case will jolt the government into taking action. “It is a tough time for us,” he says. “Each time a reporter calls me, I have to revisit the trauma of those 17-18 days. But this fight is the new normal in our lives.”

22-Rinku-SinghUp for a long fight: Rinku Singh from Uttar Pradesh has been fighting a legal battle against a private hospital in Delhi. His father, he says, died because of the hospital’s negligence.

 

The ensuing debate post this case has brought to the fore the big question—isn’t it high time that private hospitals were regulated? It is not that the government has not tried. The Clinical Establishments (Registration and Regulation) Act, 2010, besides making registration mandatory for private hospitals, provides a framework for prescribing minimum standards and facilities at the hospitals. Most states, however, have either not adopted or implemented the act; as of now, only ten states and six Union territories have adopted it. “The implementation of the act requires political will. We will be writing to the states to push for it,” says Dr Jagdish Prasad, director general of health services and chairman of National Council for Clinical Establishments. “We need this act to prevent cases such as that of Adya Singh. In the act, we have prescribed the standard treatment guidelines for 227 disease conditions, belonging to 21 clinical allopathic specialities and ayurveda.”

The need for regulating private hospitals can hardly be overstated. Last June, in the case of Karnataka-based Kristhanand, whose brother was undergoing treatment for brain tumour at a private hospital in Bengaluru and was charged exorbitant fees, the state human rights commission noted that hospital bills were “spiralling out of control”. “It may be noted that the hospital drew up a bill of Rs 10,71,917.56 lakh for 14 days for the patient. The largest single charge was a shocking Rs 3,99,690 towards clinical support services, consultation charges [were charged at] Rs 1,24,450 and consumables [at] Rs 1,55,416.63. ‘Pharmacy’ added up to Rs 67,969, bed charges Rs 96,500 and medicines Rs 67,969…. The absence of an effective framework for price regulation and lack of fee norms compromises patient’s rights to high quality, affordable health care services,” reads the note by the state commission. It also pushes for “transparency” to counter “surprise billing” and asks the government to “blow the whistle” on such practices.

Ironically, Karnataka is among the few states—including Kerala and West Bengal—that have, in the recent past, passed their own laws to regulate private hospitals and control the high costs incurred by patients. When the state government tried to introduce amendments to the Karnataka Private Medical Establishments (KPME) Bill, 2007, the move met with stiff opposition from the doctors’ fraternity in the state. Following massive protests, some of the contentious provisions were dropped, and the bill was passed in November.

In the new version, clauses such as imprisonment for doctors on the basis of a complaint have been dropped, and the grievance redressal committee has been merged with the registration committee. “These changes seem reasonable. But the clause about capping prices, which has now been removed, is a big disappointment,” says Dr N. Devadasan, director, Institute of Public Health, Bengaluru. “If private hospital doctors protesting the amendments had read the clause closely, they would have found that the state was only proposing to cap prices based on the type of hospital and where it is located. But the fear mongering created by certain doctors led to a misinterpretation that the price capping would be uniform. Several doctors came to the streets to protest against that amendment.”

Akhila Vasan of Karnataka Janarogya Chaluvali, a people’s struggle for health rights, says that though the act has a patients’ rights charter that guarantees a patient access to second opinion, right to redressal and focuses on the patients’ needs, it is not enough to prevent them from exploitation. “The irrational cost of care issue was important,” she says. “But because of the misinformation spread by some of the doctors, it slipped from the discourse. Doctors were misled by the Indian Medical Association; nowhere in the amendments was it proposed that individual doctors would be jailed. It was said that the matter would still go to the medical council, only the clinic would be shut down.” Owing to pressure from private hospital doctors in the KPME Act, price capping has been limited to procedures covered by government insurance schemes only.

25-Jayant-SinghLoss, cost: Jayant Singh with his family. His daughter Adya (right) died of dengue at Fortis Memorial Research Institute in Gurugram, and he was charged Rs 15.69 lakh for her treatment.

 

Government insurance schemes also end up benefitting only a few private hospitals, says Dr Sylvia Karpagam, a Bengaluru-based public health doctor and researcher. “A study done by the state government found that in Bengaluru, only four private hospitals were getting the major share of insurance money,” she says.

Doctors and activists also point to the issue of price cap for medical devices. “Medicines and consumables make for about 50 per cent of the bill; doctors’ fee is only 10 per cent,” says Dr Sumit Ray, senior consultant, critical care medicine, Sir Ganga Ram Hospital, Delhi.

Doctors and activists also reveal that hospitals buy consumables such as syringes, IV cannula and catheters in bulk at a cheaper price, and then sell it at a much higher maximum retail price to patients. This difference between the cost price and the MRP is where the hospital makes a “killing”, says Malini Aisola, activist, All India Drug Action Network. “Just like stents were brought under price control, the government needs to do the same for 19 other medical device categories [devices that have been classified as drugs, and hence government can cap prices],” she says. “A Rs 2 syringe may cost up to Rs 23. The markups are huge when it comes to these devices, at times up to 1,000 per cent.”

Unethical practices by hospitals such as buying from manufacturers who will keep the MRP high, making individual doctors chase targets for procedures, surgeries and diagnostics and handing out referral commissions for attracting patients need to be kept in check. “Even ASHA workers are given extra incentive to bring patients to private hospitals,” says Karpagam.

But these systemic issues apart, public health experts say that the model of private health care or health care as a “business” is essentially flawed, and undermines a patient’s benefit. While laws to regulate private hospitals are necessary, at the heart of the matter is the crisis of public health care that is pushing people to private hospitals, where they are compelled to spend huge amounts of money. “In the doctor-patient relationship, there is an asymmetry of information, that is, a doctor knows more than the patient. In such a system, direct payment is the worst form of payment,” says Devadasan. In such a scenario, what works is a prepaid model of health financing, where the citizen either pays taxes or a premium for insurance. “That way, the patient goes and gets treatment, and then the government or the insurance agency reimburses the provider,” he says. Unlike in the United States, where insurance is “commercialised for profit”, India needs to learn from Europe, where insurance is run by private players, but operates on a non-profit basis, he says.

The government also needs to focus on improving public sector hospitals, and increase its health spending. “We need a law to regulate private hospitals, and also need to strengthen the MCI,” says Dr Shah Alam Khan, professor, department of orthopaedics, AIIMS. “Look at our neighbouring countries such as Sri Lanka, where the government controls 90 per cent of health facilities. But in India, only 22 per cent of hospitals are in the public sector.”

Khan says in its health care spending, India is behind countries like Iraq and Ethiopia that spend more than 2 per cent of their GDP on health care. “The case for better government hospitals can be made when we look at the difference in costs. For instance, if a patient can get an MRI for Rs 2,000 at AIIMS, at a private diagnostic centre right outside AIIMS, costs could go as high as Rs 6,000 to Rs 8,000,” he says.

Agrees Ray, who says that while unethical practices do happen in hospitals—in the Fortis case, for instance, the gloves used for facility maintenance should not have been billed to the patient—costs can be brought down only to a certain extent, especially when it comes to ICUs. “You need structural change in health care. A corporate hospital is responsible to its shareholders, not to the patient. They need to show profits. A robust public health system will give stiff competition to private hospitals. It is only then that quality, affordability and accountability in health care will come,” he says.

Until then, many people such as Jayant and Rinku will have to wage a long-drawn-out legal battle to get some semblance of justice.

PERILS OF TOO MUCH REGULATION

India US Cayman Island HealthcareDr Devi Prasad Shetty | AP

There are at least ten bodies that patients can turn to for grievance redressal, including the national and state medical councils, consumer courts, civil courts, and even criminal courts. There is no need for any other body for that. Doctors are the most investigated among all professions. Too much regulation will lead to doctors turning to defensive medicine—they will prescribe tests that are not required just to save themselves from being prosecuted. They will always work in fear. Laws such as the Clinical Establishment Act will hurt the smaller establishments in tier 2 and tier 3 cities who don’t have the requisite documentation required. Also, there is a belief that government hospitals are cheaper, which is untrue. We are also short of health care staff. In such a situation, unless the government and private sector work together, the problems are going to increase. In the earlier version of the Karnataka Private Medical Establishments Act, there were problems. There were certain draconian measures, but they have been removed because doctors protested. The self-regulation mechanism that we are working on will be better than the KPME Act.

Dr Devi Prasad Shetty
chairman and executive director, Narayana Health

SELF-REGULATING PRIVATE HOSPITALS

24-Naresh-TrehanDr Naresh Trehan | Arvind Jain

We need to take measures to ensure transparency and increase patient confidence. Under the aegis of the Indian Medical Association, we are working on a mechanism to self-regulate private hospitals. All the stakeholders are on board, and probably by next year the rules will be out. There has to be a realistic margin on drugs and consumables. Those who overcharge must be punished. But closing down hospitals is not the answer. The complaints must be investigated and the guilty punished, but there has to be an understanding of how private hospitals work. We are also asking the government if it would like to give its inputs on the self-regulation mechanism.

Dr Naresh Trehan
chairman and managing director, Medanta-The Medicity

ENSURING ACCOUNTABILITY

27-Preetha-ReddyDr Preetha Reddy

Private hospitals are becoming accountable, and wherever there are unnecessary procedures, questions about outcomes are being asked, both at internal audits [within the organisation] and also at the board level. Clinical pathways [standardised, evidence-based care processes] are being followed at most hospitals. Self-regulation is the way forward to ensure accountability.

Dr Preetha Reddy, vice chairperson, Apollo Hospitals Group

Omission and commission

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The patient has been identified: It is India’s health care sector. The diagnosis has been made: It is a severe case of corruption, apathy and maladministration, mainly in the Medical Council of India (MCI), the apex body that regulates medical education, training and practice in the country.

The doctors—in this case, elected representatives, medical professionals and legal experts—all agree that immediate treatment is needed. But, they are still squabbling over the proposed cure, which is the National Medical Commission Bill, 2017, tabled in the Lok Sabha by Union Health Minister J.P. Nadda on December 29 last year.

The government says the bill will overhaul medical education by bringing in “transparency” and “accountability”, but the Indian Medical Association, an influential organisation that has around three lakh allopathic doctors as members, has opposed it. On January 2, the government was forced to refer the bill to a parliamentary standing committee, after the IMA began a 12-hour nationwide strike to prevent the bill from being passed.

The bill proposes to replace MCI with the National Medical Commission, a 25-member body comprising a chairperson, 12 ex-officio members, 11 part-time members, and an ex-officio member secretary. The chairperson and part-time members would be appointed on the recommendation of a “search committee”, headed by the cabinet secretary and comprising the chief executive officer of NITI Aayog, the Union health secretary and experts from the fields of law, management and public health.

Unlike in MCI, whose members are registered medical practitioners elected by ballot, the proposed commission would be constituted largely by the Union government. Only five part-time members would be elected by registered medical practitioners. A key provision in the bill is the setting up of four autonomous boards—one each to regulate undergraduate medical education, postgraduate education, medical assessment and rating, and ethics and medical registration.

The devolution of powers means that the commission will not be a regulatory monolith like MCI, which the community health expert Dr Rama Baru likened to a “medical mafia”—a nexus between corrupt doctors and politicians. Baru was part of MCI’s ethics committee, formed after its national president Ketan Desai was arrested for allegedly accepting Rs 2 crore as bribe to grant recognition to a medical college in Punjab. Baru said Desai had built a network of doctors across the country, and had tied up with politicians to sanction medical colleges in exchange for bribes of several crore rupees. “Those within the profession had lost trust in MCI,” said Baru.

In 2016, a parliamentary standing committee chaired by Ram Gopal Yadav, MP, found that there were “issues related to corruption” in MCI, and that it had failed to fulfil its responsibilities. “The quality of medical education is at its lowest ebb; the current model is not producing the right type of health professionals…,” said the report.

25-vikramgad-weekDoctors in demand: Patients waiting outside a rural hospital at Vikramgad in Maharashtra | Amey Mansabdar

 

Apart from replacing MCI with the decentralised commission, the bill also envisages a medical advisory council, which will help the commission shape policies and initiatives related to education and training. The council will have members nominated by states and Union territories.

“The idea is to shift from election to selection; and the search committee would select candidates through transparent processes. The professionals nominated by the government would be persons of high integrity,” said a NITI Aayog official who was involved in the drafting of the bill.

The move from election to nomination has been welcomed by doctors who feel that MCI elections were rigged. “Good doctors would also not vote, because they didn’t trust MCI,” said Dr Samiran Nundy, senior consultant at Sir Ganga Ram Hospital in Delhi.

The IMA, however, has sharply criticised the commission’s “bureaucrat-heavy” composition and its “inadequate representation” of medical professionals. “If the government had wanted a leaner body than MCI, it has not reflected in the bill,” said Dr K.K. Aggarwal, former IMA national president. “With a total of 150 members in the commission, the number exceeds that of MCI (130). Decision-making powers are now concentrated with the three members [each] of the four autonomous boards.”

Baru said the bill did not address the issue of breaking the nexus between corrupt doctors and politicians. Rather, she said, by giving complete control to bureaucrats, the bill leaves the system even more vulnerable to “political interference, lobbying for posts and manipulation”. Baru, too, feels that the representation of those within the medical fraternity is inadequate.

The bill has also been criticised for proposing lax procedures in inspecting private medical colleges and regulating fees. Under MCI, a medical college would undergo “phase-wise” inspections before being granted recognition. MCI could debar colleges who repeatedly fail to meet the standards, and, in extreme cases, even de-recognise them.

One such case is that of Chintpurni Medical College at Pathankot in Punjab, which received permission to begin operations in 2011-12, and was later debarred after subsequent inspections revealed deficiencies related to faculty and facilities. Dr Sushil Garg, president of Chintpurni Medical College Parents’ Association, said the college continued to function even after being debarred. “During inspections, they [college authorities] would manage faculty requirements by bringing in ghost faculty [faculty that would only exist on paper],” said Garg. “Once, during an inspection, which was conducted on counting day [of an election], the management told MCI inspectors that no teachers were available because it was a government holiday. It was untrue. The holiday was on polling day, not counting day.”

Instead of improving on the existing regulatory framework, the bill proposes to do away with the “inspector raj” altogether. It says “third-party agency or persons” can be hired and authorised for inspecting, assessing and rating medical institutions, and proposes monetary penalties in case of any violation. Officials at the health ministry say the idea is to “open up” the sector, get more private players to set up medical colleges, and ensure that there is “greater supply” of quality medical professionals.

“MCI’s inspector raj had created fear among honest, genuine investors who wanted to set up medical colleges, and created a mechanism for blackmailing them in return for approvals,” said the NITI Aayog official. “This bill will allow honest people to set up colleges and address shortage of doctors.”

As per the bill, a key function of the commission will be to “frame guidelines for determination of fees in respect of such proportion of seats, not exceeding 40 per cent in private colleges and deemed universities”. Experts feel that it leaves room for market forces to commercialise medical education. “Why only 40 per cent? That, too, up to 40 per cent, which means zero to 40?” asked Sujatha K. Rao, former Union health secretary. “There are Supreme Court rulings directing states to constitute tariff committees to arrive at reasonable fees. Why is that being diluted? What if a private college charges 050 lakh a year? What is the oversight mechanism for overcharging and exploitation?”

She also disagrees with NITI Aayog’s argument that investors get returns through fees. “Why is medical education being treated as an investment, when the global view is for treating it as a public good? Why should one need 0400 crore to set up a medical college? This clause will only create inequity, restrict access to a large number of meritorious [students] who want to become doctors, and make availability of doctors in rural areas or for primary care impossible, and medical care expensive,” she said.

To solve the shortage of doctors in rural areas, the bill proposes a bridge course “for practitioners of homeopathy and of Indian systems of medicine to enable them to prescribe such modern medicines”. The IMA has bitterly opposed this clause, saying “unscientific mixing of systems… will only pave the way for substandard doctors and practices”.

“Since 2010, the government has been pursuing the idea of strengthening subcenters with a cadre of public health doctors trained for three years in medical colleges, much like the ‘licentiate in medicine and surgery’ in the British times,” said Rao. “This later spun into a bridge course of six months or so for AYUSH practitioners who are trained for five years, empowering them to prescribe a list of allopathic medicines.”

Rao feels that this provision, in its current form, can be abused, by way of legalising the current practice of AYUSH doctors prescribing allopathic medicines. “It will also enable them to pursue sham courses and work at any level, not just primary care,” she said.

Anupriya Patel, minister of state for health, told THE WEEK: “Any decision to allow bridge courses in modern medicine to AYUSH practitioners will be taken only by unanimous consent of all members present in the annual joint sitting of the NMC, and the councils for homeopathy and Indian system of medicines. Every single member will have a right to veto the proposal. Hence, there are strong safeguards provided. Detailed procedures and guidelines would be prescribed before any such decision is taken in the joint sitting.”

The bill also provides for conducting a licentiate exam, or an exit test for MBBS graduates to maintain standards. But experts have opposed this provision, too, saying the focus should now be on providing quality medical education.

“This test is desirable, but India is not ready for it, though a three-year period has been given for it to get operational,” said Rao. “For ensuring and maintaining a standard, the examination will have to be above average. This will mean that students from several backward states who cannot afford private tuitions may not be able to crack the examination. There will be a lot of problems in the interim, till such time that college standards do not improve.”

The life of a remarkable fighter and survivor

This doctor’s life, against the odds of kidney disease, ought to be a beacon of hope for all in similar circumstances

Dr. Georgi Abraham

Robin Eady, dermatologist and survivor extraordinaire, created a record for the longest number of years on dialysis, before he got a kidney transplant. When he passed away in August 2017 at the age of 76, he left a legacy of hope, motivation and determination for millions of renal failure patients, as the longest surviving kidney patient in the world. The Royal Society of Medicine in London dedicated an evening to celebrate his remarkable life.

Born in Egypt in 1940, Robin enjoyed a relatively privileged childhood and early youth, before being diagnosed with kidney failure at 23. He was given just a few months to live. Ground-breaking advances in medical science and access to treatment at the right time, together with his resolve to hang on to his health against all odds, made it possible for him to live a full life. That included the pursuit of an eminent professional career.

Ian Reekie, who started medical training with Robin Eady in 1959 at Guy’s Hospital in London, became his close friend. At the Royal Society event, Dr. Reekie recalled the onset of Robin’s disease in 1962 and admission to Hammersmith Hospital. Dialysis was not available then in the U.K. or the rest of Europe, and the future seemed hopeless. Robin’s parents had read about the ground-breaking procedure that Dr. Belding Scribner had started in Seattle, U.S., and got Robin accepted for treatment. Robin spent two years in the U.S. and Canada and finally returned to London to continue dialysis at the Royal Free Hospital in Hampstead under Dr. Stanley Shaldon.

Joy Bennett, who started nursing with Ann (and who became Robin’s wife), worked on the renal unit at the Royal Free Hospital. She remembers the arrival of Robin who had just come from Canada: he was not only self-sufficient but knew a lot about dialysis. Robin made it clear he would continue with his medical studies.

After Ann and Robin married, Joy and her husband Adrian remained friends, especially after Robin’s transplant in 1987, when dietary restrictions he had endured for years were lifted! Up until his transplant, Robin was the person who had survived the longest on dialysis.

Alastair Heath could be called Robin’s kidney-twin, as they were jointly the beneficiaries of a young woman donor. When the transplant took place, Robin had been on dialysis for 25 years, 19 of which were at home. This was not Alastair’s experience, however, as he had not been on dialysis. The ‘twins’ met annually to remember their good fortune.

As an eminent dermatologist, Robin is remembered for his innovative research into EB (Epidermolysis bullosa), that causes blisters. He passed his professional examinations during his time on dialysis. He was awarded an honorary fellowship of the Royal College of Medicine, a fellowship of the Academy of Medical Sciences and an MBE for services to charity and medical science.

Appreciating his own good fortune, Robin travelled the world, talking to various organisations as a survivor of dialysis, and in addition to recording his own experiences, he never failed to inspire others about the possibility not just of recovery but of returning to work and enjoying all that life has to offer.

Delivering the Krishnan-Ang endowment lecture organised by the TANKER (Tamilnadu Kidney Research Foundation) in Chennai in February 2010, he said, “After 47 years of coping with renal replacement therapy, I can say good family back-up and being a bit selfish about one’s own needs does help.”

Robin died in London following heart surgery.

Dr. Georgi Abraham is a nephrologist based in Chennai

A poor prognosis: the National Medical Commission Bill

Dr George Thomas

There is no doubt that the Medical Council of India (MCI) has outlived its utility and should be reformed or replaced. The remit for the proposed new body, the National Medical Commission, should be clear, direct and workable. A regulatory body should be expected only to regulate and not to formulate policy, which is the function of Parliament and requires inputs from a number of sources, preferably with different points of view.

The fundamental flaw in the proposed Medical Commission is the lack of clarity on its function. Unfortunately, in the National Medical Commission Bill, 2017 in the chapter titled “powers and functions of the commission”, the phrase “lay down policy” occurs repeatedly. The Commission is also expected to “assess the requirements in healthcare, including human resources…” Such complex tasks, which require inputs from multiple agencies, will be done poorly, if at all, by the commission. The Commission should only be expected to monitor and regulate the training of health-care personnel and maintain professional standards.

Point of integration

What type of medical practitioners should the country train? This is a matter that the government should decide. It is poor policymaking to smuggle in clauses about interdisciplinary meetings between different medical systems and bridge courses into this Bill, under the omnibus “miscellaneous” section (item number 49). The failure of successive governments to promote scientific medicine and integrate the best of indigenous systems into one unified system has led to unhealthy competition among the various streams of medicine in India. It must be emphasised that modern medicine is wrongly labelled “Western”or “Allopathy”. Modern medicine takes all that is useful in therapy regardless of its source. It subjects every treatment protocol to the impartial tests of science. “Allopathy” is a term coined by Hahnemann, the founder of homoeopathy, and is seldom used in countries other than India. It would be great statesmanship to move to just one scientific system of medicine in India, combining all that is proven from different streams.

Who should the members of the Commission be? The present system of appointing members to the MCI has failed, resulting in rent-seekers repeatedly entering the Council. The present method of election, where potential candidates have to spend quite a large amount of money and time to get elected, has the unfortunate outcome of ensuring that mostly rent-seekers seek election. The election process should be reformed, not replaced. The proposal to have sections of society other than medical professionals in the commission is laudable. Having an almost entirely nominated commission, as the present Bill provides, is unhealthy. It will lead to a collection of ‘yes men and women’ whose chief qualification will be proximity to the existing government.

Medical education

Should private initiative be allowed in medical education? If the government is sincere in its objective of providing universal medical care, it is clear that high-cost private education will further exacerbate the problem of too many specialists in metropolitan areas chasing too few patients. Many ethical problems in India arise from this basic situation of too many doctors chasing too few paying patients. Issues such as unnecessary investigations and procedures, and too little time spent with each patient arise from the need to earn a reasonable amount and the need to do it from the small pool of paying patients. More importantly, such policy decisions should not be left to the Commission.

To start a medical college, State governments first issue a certificate of essentiality. The MCI then decides whether the proposed college has enough facilities to start the first year. Subsequently, inspections are done every year till the first batch of students has completed the final year. This has led to problems, as somewhere along the way, the Council finds that some colleges are unable to meet the requirements and withdraws recognition. This leaves students in a lurch and they then approach the judiciary to solve their unhappy situation. The proposed Commission has no mechanism to prevent this from happening. Merely shifting this responsibility to a medical assessment and rating board is no solution.

The present Bill is unlikely to provide a dynamic new thrust to medical care in India. It falls between the stools of excessively ambitious objectives and micro-management. On the one hand the Commission is expected to formulate policy, but on the other it is to decide fee structure. The government should exhibit statesmanship and form a parliamentary committee to draft a new Bill altogether with clear and workable objectives. In the end, policy decisions should be decided by policymakers, and not bureaucrats.

George Thomas is an orthopaedic surgeon at St. Isabel’s Hospital, Chennai