Keywords: medical education, regulation, governance, reform, health policy

I read the editorial “Ethics regulation by National Medical Commission: No reason for hope” by Amar Jesani with keen interest [1]. The article raises many pertinent issues which need urgent policy attention. Institutions and governance for regulating medical education and practice in India carry a significant colonial legacy of British rule [2]. No major reform was carried out to change the status till 2019. The recent reform in apex medical regulatory institutions, replacing the erstwhile Medical Council of India (MCI) with National Medical Commission (NMC), was a result of long-term demand. Several previous attempts to reform MCI had failed, despite recommendations by various committees, including the high level parliamentary standing committee [3].

Expectations and challenges

This long-awaited reform gave rise to a higher expectation, but the delay in creation and commencement of the functioning of NMC caused confusion. This also allowed an extended term to the Board of Governors (BoG) of the MCI, which was running affairs in the interim. The BoG was a highly centralised body which took many far-reaching policy decisions without the required deliberation [3]. By the time NMC was constituted and started functioning in September 2020, the challenge of the ongoing Covid-19 pandemic and disruption in medical education pushed NMC to start functioning in a similar manner to the erstwhile MCI. As pointed out by Jesani, even the appointments of presidents and members of different autonomous boards took an exceptionally long time. Jesani also highlighted the contradiction in the claim of the NMC being diverse, as the “Ethics and Medical Registration Board” is composed of only medical doctors [1]. A look at the composition of other boards also indicates similar gaps. For example, in the “Undergraduate Board”, out of four members, only one is from a broad speciality department with direct engagement in undergraduate teaching. The other three members are from super-speciality departments or super-speciality centres [4].

Regarding ethics in medical regulation by the NMC, Jesani raised important questions on intent and implementation challenges. The implementation of ethics regulation and professional conduct remain with the respective State Medical Councils (SMC). NMC is just an appellate body for ethical issues. Therefore, it is important to investigate the status and functioning of SMCs.

Composition of State Medical Councils and implications

A state-level legislative Act governs the formation of an SMC in any state. The provisions of these Acts and the criteria for appointing the president and members are quite heterogeneous across states. Most state-level SMC Acts were enacted long ago, and many of them can be traced back to colonial era legislations. These SMCs continue to be controlled by doctors or serving bureaucrats of the health department in most states. There is hardly any representation for a non-medical person or civil society in SMCs. To understand this more systematically, I conducted a rapid online search of the official SMC website, and websites with information on SMC members in July 2022. Information on the composition of SMC in 21 large states and one Union Territory (UT) was extracted (see note for the list of states and UT)*. Data were compiled and analysed to ascertain the professional background and affiliations of the presidents of these 22 SMCs.

Overall, the findings suggest continuing dominance of a “medical or bureaucratic elite” in leadership positions. Out of 22 SMCs, 19 were headed by a medical doctor as president, while three SMC were led by serving bureaucrats of the Indian Administrative Services (IAS). Among 19 doctors heading SMCs, nine work in the public sector, either in medical college or state government services, and other nine work in private sectors such as corporate hospital, private medical colleges, or private practice. Three SMCs were led by IAS officers posted as director of health. The affiliation of one doctor could not be ascertained. A few SMC presidents are representatives of the Indian Medical Association (IMA), a professional association of medical doctors in India. One doctor leading a SMC is also a Member of the Legislative Assembly (MLA) in the state. The process of selection of president and members of SMCs is diverse. In some states, the SMC president and members are either selected or nominated, while some SMCs have a mix of nominated and elected members. There is no clarity on the criteria for selecting members and the proceedings and implementation of ethical codes. Most SMC websites do not have information on the number of ethics-related complaints received and their status.

Implementing important and complex policies, such as the SMC Act require “state capacity”. In the absence of capacity and owing to the prevailing state of the political economy in states, such regulatory institutions often suffer from capture by “professional elites”. This undermines the fundamental objectives, such as ensuring ethical practice. Ensuring ethics standards and professional conduct would remain incomplete without effective reform at the state level and revamping and empowering SMCs. The national-level reform will remain half-done in the absence of state-level action.

*Note: Composition of following state medical councils included in the analysis

Andhra Pradesh, Assam, Bihar, Chhattisgarh, Delhi, Gujarat, Haryana, Himachal Pradesh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Kerala, Uttarakhand, Uttar Pradesh, West Bengal, Jammu and Kashmir (UT).

Vikash R. Keshri ([email protected]), Senior Research Fellow, The George Institute for Global Health, New Delhi, INDIA; PhD Candidate, The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, AUSTRALIA