India has a gargantuan medical education system, one of the largest in the world. Its 412 medical colleges – public and now increasingly private – produce 52,215 graduate doctors and 25,577 postgraduate doctors a year. And yet these figures are woefully inadequate to serve even the basic needs of majority of people. To increase the number of doctors to meet the growing demand, the criteria for opening new medical colleges were relaxed. That has increased the share of doctors coming out of private colleges (212 of them prepare 25,095 graduates a year), but more than 60% of these colleges are limited to the four southern states and Maharashtra. The new institutions coming up too are mostly in potential profitable areas – in spite of the Medical Council of India (MCI) regulation. Also, most colleges prefer to cater to urban areas, leaving the already ailing rural health system untouched.


Are we serious about college assessment?

MCI’s primary task is to ensure standards of medical education, and for this, assessing whether an upcoming medical college is worth granting permission is its primary function. But it is well known that many colleges adopt illegal measures to get MCI recognition.

This has trivialised the assessment process leading to falling standards – which, if not checked, will have serious consequences. Complaints of irregularities here come in two varieties: either recognition is granted for monetary benefits (alleged by rivals) or recognition is withheld for similar reasons –both resulting in litigations by medical colleges. A key criterion in recognition is the numbers and qualifications of faculty and patients as well as the infrastructure facilities. Most complaints are about ‘ghost faculty’ and ‘ghost patients’ deployed to secure recognition.

In other words, when the MCI inspection is due, the college brings in the faculty and patients for a day of make-believe – after paying them, of course. In fact, agencies have come up to arrange for everything needed on the inspection day – from faculty to even equipment and books in the library. There have been instances of colleges whose buildings are yet to be constructed – or even land is yet to be acquired, though they have collected fees from students and started classes. Another level of the problem is the assessor – he or she is human after all, and prone to making mistakes. He may be either plain ignorant or can feign ignorance and turn in a favourable report or highlight nonexistent deficiencies. Either case could be a matter of chance or fixed.

Those in MCI who decide on which assessor to send where would have a good idea of the assessor’s skill or the absence of the
same. They can send the ‘right’ assessors to get the required outcome. Assessment is a two-stage process. In the first round, deficiencies, if any, are pointed out, and then there’s second assessment to see if those issues are addressed. Usually, in cases of irregularities, the pattern has been that the first assessment would apply all the standards strictly and point out all the deficiencies. But the compliance report as well as the subsequent reports would show absolute compliance.

Again, it is up to the decision-makers within MCI if they want to go for a second compliance assessment or grant permission based on submissions made by the medical college. These tactics are not limited to private colleges. The MCI has often granted permission to government colleges based on mere assurance of the government.

For example, in 2015, MCI barred seven of the 16 private medical colleges in Uttar Pradesh from offering the MBBS course but allowed
government colleges to do so despite deficiencies pointed out in the assessment – after assurance from the principal secretary (medical education) that the issues raised would be addressed soon.

Regulatory overkill or slackness or both?

The problem is compounded by contradictions in the rules and regulations themselves. One rule specifies a certain number of beds at various stages of recognition renewal, whereas another rule shows a different number. One rule prescribes a particular patientstudent ratio, and a later amendment has another figure. It is, of course, up to the MCI to pick and choose rules and regulations in a given case.

The student-teacher ratio has been worked out by MCI to ensure teaching standards. MCI has not done anything meaningful to fix the problem of ghost faculty and ghost patients though good IT solutions are available now. MCI, now under the pressure of media, has initiated some steps by procuring hardware – servers and so on. But hardware on its own will not solve the problems unless real-time monitoring is done. That brings us to the question who will monitor it. Can MCI monitor effectively with just one doctor for the job – Dr Reena Nayyar, who is incidentally also the officer-in-charge secretary in the absence of a fulltime secretary. It remains to be seen if it wants to use technology to fix the problem. Seamless software for all major processes is urgently needed. Today software for various processes do exist but these are not seamless defeating the purpose of speed in generating realtime reports, transparency, objectivity and so on.

A few years back, when Dr Ketan Desai was the MCI president, a lot of money was spent on smart cards for a biometric attendance system. MCI did not implement it.

Ironically, MCI, with a mandate to regulate standards of medical education, has no set standards when it comes to the staff strength of its own organisation. At present, MCI is running with only a single doctor for more than a year as other senior staffs remain suspended. MCI has no full-time secretary for four years and is in no hurry to appoint one. The council has given commitment in the high court that they will not fill up the post until recruitment rules for the post are decided by the court and a perusal of court proceedings shows that MCI is seeking adjournments. Similarly, the case filed by the previous secretary challenging her termination is also pending in the central administrative tribunal (CAT) for four years, taking 46 listings so far.

Obviously, slackness should be expected and slips will occur with one lone doctor managing the entire office when other doctors/senior staff remain suspended for years over one or the other charge.

Trivialisation of medical entrance and examination

The practical/clinical examination is an important part of the summative assessments of students under medical training. According to a paper published in the Journal of Pharmacology and Pharmacotherapeutics, “In many departments throughout the country, the university examinations are annual rituals which are eagerly awaited by staff and faculty for various reasons ranging from breaking the monotony of the routine work to getting some financial benefits. With increasing amounts being paid as remuneration by universities, financial incentives become a major motivating factor for many faculty members to accept examinership.

This brings into play numerous conflict-of-interest issues as universities prefer to select only ‘good’ examiners, which translates as those
who pass all students whether they deserve to pass or not. These ‘good’ examiners close their eyes to all unethical practices such as leaking the spotters and questions that are asked, having a deal with internal examiners that they will award maximum marks for every
student, accepting hospitality that is paid for by the students, and so on.

“Society trusts examiners to determine the competency of medical students and permit only the fit ones to practice medicine, thereby safeguarding the interests of people. This is and should be honoured, respected, and undertaken as a task bestowed with great responsibility. Society is dependent on a trained expert for this important decision-making task. Hence, it is our professional obligation to accomplish this task with the integrity and sincerity it requires. Trivialising assessment has become one of the leading contributors to falling standards in medical education and which, if left unaddressed, will have serious consequences.”

Role of MCI

MCI is deliberately turning a blind eye to the old problem of corruption and allowing it to continue. In order to bring uniformity in admission criteria, former MCI chairman Dr SK Sarin notified a merit-based national eligibility entrance test (NEET) as well as an exit test. It ran
into controversy as the health ministry was under the influence of the lobby of private medical colleges and it was never implemented. Despite court orders, fees of private medical colleges remain largely unregulated. MCI leaves it to the state fee fixation committees which
seldom function. Even if they function, there is no one to monitor them. An amount of '50 lakh is being spent for MBBS and '1-2 crore is being spent for post-graduation. This makes medical care quite expensive as fresh graduates often embark on unethical practices to
secure return on their investment.

Outdated academic curriculum

One of the major mandates of MCI is to frame academic curriculum and make changes from time to time. While MCI is busy in granting permissions for opening new medical colleges, it has lagged behind with the advances in the medical field and medical education
technology. For 20 years, no significant changes hav ebeen made in the undergraduate medical curriculum.

The current system of affiliating colleges which do not meet the minimum standards and passing underserving candidates would generate a huge crowd of incompetent doctors. Unless MCI plays a regulator’s role sincerely, country would never get good doctors for future. In the long run, makeshift medical colleges will only worsen the condition of our already sick health sector. It is high time that we should focus
on quality over quantity. Ensuring the quality of medical colleges, especially in the private sector, and making accreditation restrictions more stringent are the need of the hour.

pankaj@governancenow.com

(The article appears in the March 1-15, 2016 issue)