Anand Zachariah, George Mathew, M.S. Seshadri, Sara Bhattacharji & K.S. Jacob
The opportunity to recreate the regulatory council for the education of health professionals is historic in its possibilities and potential to address the crisis facing health care in India. The lack of access to basic health care due to inadequate numbers and the skewed distribution of health care providers mandate urgent action. The new council should address these issues, in addition to ensuring propriety, increasing efficiency, and providing greater synergy among professionals.
The new National Council for Higher Education and Research (NCHER) Bill seeks to include medical education within the purview of the proposed council. The regulations suggested include facilitation, coordination and setting of policy by the NCHER, a health council to consider syllabi, curricula and exit examinations and local universities to regulate academic institutions. It is not clear how the NCHER Bill will address the specific requirements of education of professionals. Concurrently, the government has also proposed the formation of a National Council for Human Resources in Health (NCHRH) as a single apex body to oversee all education and practice related to health. It is apparent that there will be an overlap of functions between the two authorities.
Many issues mandate the need for a separate regulatory authority for health education and practice.
Links to health care delivery: The need to provide health services for a society demands the setting up of a system, which will sequentially address the following issues: selection of students from local areas, sufficient training in primary and secondary care hospitals, generalist postgraduate training opportunities (example family medicine), career opportunities in areas of need and continuing educational support. Such a system will mandate close linkage between educational institutions and the health care delivery systems.
Apprenticeship model of training: The education of health professionals requires that they achieve a high level of expertise at the end of the training. This requires that students acquire considerable clinical skills by taking care of patients under the supervision of teachers in an appropriate service environment. Such a model allows for narrowing the divide among teaching, research and practice. It facilitates a holistic approach to learning in health sciences and captures the essence of the Yash Pal Committee report.
Regulating health professionals: Overseeing the health profession and its professionals is an important task of any regulatory authority set up for this purpose. As medical education and eventual practice are a continuum, the regulation of education must be coupled with the regulation of practice. Across the world, experience with dual regulation has shown that it leads to a lack of coordination in training. For example, the United Kingdom established dual control of higher education and professional regulation by separate authorities (the General Medical Council and the Postgraduate Medical Education and Training Board) only to disband the model and revert to a single body for the oversight of both functions.
The problems of the past demand a re-examination of regulatory issues. The enabling Act, which constitutes the NCHRH, should clearly specify the model, framework and process in order to promote ideal functioning. Some important issues are highlighted.
Relationship between health disciplines: The proposed regulatory council includes medical, nursing, dental, pharmacy, paramedical, public health and rehabilitation services. A single regulatory authority will result in greater coordination and collaboration among these disciplines.
Composition of the authority: The new authority should be composed of diverse stakeholders, including patient advocacy groups and social scientists, in addition to distinguished medical and health professionals so that the overall health care needs of the country, rather than narrow professional interests, are the focus. The council should not be too small as that can lead to the concentration of authority in a few hands. Nor should it be so large as to be divisive and inefficient.
Independent accreditation and regulatory functions: The Medical Council of India handled accreditation and regulatory functions; this diluted and weakened both processes. The new authority should consist of two independent divisions: one accrediting education and the other overseeing professional practice. The complete lack of self-regulation of the past argues for a watchdog with sufficient teeth to ensure and enforce adequate technical and ethical standards in medical practice.
Model of accreditation: The new model of accreditation should move away from reliance on detailed prescriptive rules on structure and processes to that which describes broad principles and standards, focussing on outcomes. This will allow for flexibility and innovation while maintaining basic standards. A credible and transparent system of assessment, which balances routine self-report and review with monitoring and on-site inspections, needs to be designed.
Relationship with the government: The need for autonomy and independence of the regulatory body is crucial. Subjecting its decision to Health Ministry approval limits its role and delays decision-making. However, the government should have the power to provide overall policy direction to the body. In turn, it should also serve as the consultative body for the Ministry.
Relationship with hospitals, universities and specialist associations: Currently, basic medical and health degrees are within the purview of local universities. The vastness of the country and the large numbers of students mandate decentralisation of the educational process with local autonomy for universities and medical institutions. However, the need for uniformity mandates defining competencies required for basic medical and health personnel.
Now, all postgraduate qualifications are university degrees. While these degrees are supposedly academic credentials, in practice they focus only on clinical issues and skills. The academic component of the training that requires evaluation of competencies to carry out research is missing. To meet this requirement, a separation of medical and health care personnel into clinical and academic streams, as practised in many countries including the U.K., is a useful concept to consider. Specialist associations should conduct standardised exit examinations for clinical fellowships and oversee clinical streams. The academic stream should be upgraded to a research degree and should remain within universities. This separation will avoid the kind of conflict, which was common between the MCI and the National Board, increase the number of centres for training clinicians and raise the standard of research.
Single window: Previous regulatory procedures involved separate and independent inspections by the MCI, the university and the State government. This resulted in a many-tiered system that led to huge delays in obtaining approval. A single window for accreditation and approval of education is necessary.
Standardised exams and validation: A common licensing examination for undergraduate and postgraduate courses is necessary to maintain uniformity of defined technical standards. All health professionals should be required to maintain standards of professional knowledge and skill through regular re-validation. A system of continued education and credits and regular re-appraisals is also mandatory.
Transparency and accountability: The system should be transparent, accountable and open to public scrutiny. A record of excellence in one’s field should be the basis of selection to the proposed council. The Nolan Principles — selflessness, integrity, objectivity, accountability, openness, honesty and leadership by example — should form the standards for holding public office and in public service.
The Knowledge Commission and the Yash Pal Committee, which examined higher education, identified major lacunae and suggested an overhaul of the system. Many issues raised in their reports are very relevant to medicine and to education related to health care. There is need for broad-based holistic education and for dialogue among the diverse disciplines and centres of learning. The regulatory council should act as a facilitator and catalyst for the creation of knowledge for society.
While there is need to reform the entire higher education, the inclusion of education related to health within the NCHER may not be the ideal framework. The NCHER can foster an interdisciplinary research and identify national priorities. It can empower institutions with a proven record to enhance their autonomy as institutes of national importance. However, a new, separate and reformed regulatory authority, the NCHRH, best serves the goal of improving education in health sciences. It must ensure that education in health disciplines fulfils its social mandate. It should not only regulate education but also provide a vision to improve health care delivery.
(Professors Zachariah, Mathew, Seshadri, Bhattacharji and Jacob are on the faculty of the Christian Medical College, Vellore. This document was prepared in discussion with faculty from the institution and from other national and international medical schools and health networks.)
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