Regulating Medical education

Regulating Medical education
Efficiency and quality are difficult to be defined just by the presence of an individual or an institution in spacetime,unless in the long run ,time proves the outcome of the individual/institution .We can try to quantify by hours of work done by each individual,output from each institution,yet the number of hours does not always depict quality.The same hours of work,in the same discipline done by two different individuals need not be of same quality and efficiency .The workload of teachers of higher education (as shown in page 64. Item 7.57 ,UGC committee 1992 ) is as follows:
ACTIVITY AVERAGE NUMBER OF HOURS PER WEEK
PROFESSOR READER LECTURER
Teaching 6 8 10
Tests/exam 1 1 1
Tutorial 1 2 4
preparation 6 8 10
research 14 14 10
reading/administration 12 7 5
total 40 40 40
In the case of a pathologist,who is also a medical teacher ,and whose time of work is from 8 AM to 4 Pm (1 hour lunch) the weekly 56 hours have to be divided also for diagnostic,consultancy,discussion and lab work .Therefore ,what we do is ,make an arrangement of division of labour and rotate between the teaching,diagnostics work. Suppose there are only two professors in a pathology department and one of them refuses to take up any teaching /administrative work and opts only for consultancy and diagnostic work what measures should an administration take ? If the other professor is willing to take up entire responsibility of teaching,research and administration,curriculum planning,syllabus and the paraphernalia associated with it ,the administration should be happy to have avoided a strife .But in fact ,a responsible administration should make the professor see that teaching also is part of the work of a professor of an institution of high excellance.
Even when there is division of labour between the professors,they can consult each other regarding difficult problems of diagnostic work, exchange ideas on clinical and clinicopathological work and keep the excellance of the institution high .Quality in administration,in teaching and in consultancy and administration is the total personality development each pathologist strives for and each institution should look for .But usually ,the administration fails to see such overall total quality/personality development .CCharaka ,an ancient Indian medical personality defined human personality development in 16 different ways,7 of them sathwik,6 of them Rajasic and 3 of them thamasic.
Sathwik personality is Kalyanagunavisishta (full of auspicious qualities) rajasic personality is Roshagunavisishta( full of anger which if turned against injustice will help nation,but if directed to persons/group of persons will lead to cruelty and injustice ,wars),and thamasic personality is mohagunavisistha( with quality of desire) and not fit for intellectual quality work. The upward mobility from thamasic to rajasik and from the rajasik to sathwik is possible by proper guidance and guru tries to upgrade the shishya on this ladder of excellance .
1Sathwik :-
A .Brahmasathwa-intellectual,ethical,scientific,philosophic,aesthetic,truthful,control senses ,unselfish
B .Aryasathwa –visionary ,ability to grasp meaning of science,hospitality,controlled senses and unselfish
3 Aindrasathwa-powerful and enthusiastic speech,memory and ability to foresee
4.Yaamyasathwa –mental power to suffer any hardship,to do work without tiredness,memory power
5.Varunasathwa- Calm,bold,do work without getting tired,give to deserving people liberally,love to play in watersports
6 Kouberathathwa-Interested in worldly life,marriage,makes money and lives comfortably,does both religious and secular duties
7.Gandharvasathwa- music,dance,drama,history,storytelling,smell(perfumes),flowers,luxurious ornaments and cloths,life with beautiful women
2 Rajasic –
A Asura(also called daanava since they give alms readily and are having dharmikarosha ).Mahabali rose from this to Aindrasathwa ,and Prahlada to Brahmasathwa ,and Viswamithra first to Aindra,then in order to Arya and Brahmasathwa .
B raakshasa(selfish desires make them do sins)
C paisacha ( heinous crimes are done by them due to intense worldly desires)
D Sarpa( stoop to any low level and do any heinous crime for selfish motives)
E praitya –unfulfilled desires make them wander along thinking of the desires
F saakuna – same type ,the desirous mind flows like a bird
3 Thamasic :
A Paasavan – eat,drink,sleep and makes children .No other interest .Just like an animal( pasu)
B Maatsyan – coward,idiotic,love flattery,fickle,love travels in water /ocean
C Vaanaspatyan- lazy,sits without doing anything ,no intellectual or physical activity at all
At present education is becoming a consumer cost and resultconscious commodity ,especially at higher levels,where student fees have become exorbitant ,and the education is perceived as a provider of services and benefits .This on one hand prevents the equitybased services and benefits to all citizens alike ,and a double type of organizations /institutions are emerging ,along with different type of citizens at two ends of the spectrum . Nation struggles to overcome this and by a series of efforts/discussions come up with solutions to combat them.The success indicator of a nation/institution/individual is a personal/practice development plan and finding out solutions to all problems . The UGC committee report of 1992 had suggested a few solutions (in which the then Finance minister Sri Manmohan singh and HRD minister Arjun Singh had contributed their ideas too) and the current bill in the parliament has to be seen as an extension of the recommendations of that committee .Instead ,most of the states and institutions and individuals view it as if it is a new bill (probably because they are ignorant of the recommendations of 1992 committee ).
1.THE HINDU REPORT :-
The Hindu on Saturday July 10th 2010 (Anand Zachariah,George Mathew,M.S.Seshadri,Sara Bhattacharji,K.S.Jacob) says the complexity of issues related to education in medical and health disciplines demands a separate regulatory authority.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 healthcare in India.According to them,the council should address issues like lack of access to basic healthcare due to inadequate numbers,the skewed distribution of healthcare providers,ensuring propriety,increasing efficiency,providing greater synergy among professionals.The new national council for higher education and research (NCHER)bill seeks to include medical education under purview of the proposed council.The regulations suggested are:
Facilitation,coordination,setting of policy by NCHER
Health council to consider syllabi,curricula and exit examinations
The local universities to regulate academic institutions
How NCHER bill address specific requirements of education of professionals not clear.
Concurrently the Government has proposed formation of 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.
A separate regulatory authority for health education and practice is mandatory due to :-
1 Links to health care delivery: Need to provide health service to society demands setting up 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,for example family medicine,career opportunities in areas of need and continuing educational support .Such a system will mandate close linkage between educational institutions and healthcare delivery systems.
2.Apprenticeship model of training: At end of training the health professional should get a high level of expertise.Considerable clinical skill,under the teachers in a appropriate service environment.Such a model allows narrowing the divide between teaching,research and practice.It facilitates holistic approach to learning and captures the essence of yashpal committee report .
3.Regulating health professionals : Education and practice of medicine is a continuum and the regulation of education has to be coupled with that of practice.UK first established a dual control(General medical council and Postgraduate medical education and training board) and discarded the model and reverted to single body for oversight of both functions.
The authors ,who are professors of Christian medical college Vellore shows concerns over some certain highlighted issues .Their concerns are :
1.Relationship between health disciplines :The proposed regulatory council includes medical,nursing,dental,pharmacy,paramedical,public health and rehabilitation services.A single regulatory body /authority will result in greater co-ordination and collaboration among these disciplines.
2.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 overall healthcare needs and not narrow professional interests are the focus.The council should not be too small so that the power is concentrated in a few hands.Nor should it be too large so that it is divisive and inefficient
3 Independent accreditation and regulatory functions.MCI handled accreditation and regulation and this diluted and weakened both processes.The authority should have two independent divisions. One accrediting education and the other oversee practice.Lack of self-regulation in past,argues for a watchdog to ensure nd enforce adequate technical and ethical standards in medical practice
4.Model of accreditation: Should focus more on describing broad principles and standards that focus on outcome.This will allow for flexibility ,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.
5 Relationship with government: Need for autonomy and independence of the body is crucial .The authors think that subjecting it to health ministry approval limits its role and delays decisionmaking.Government should have power to provide overall policy directions to the body and the body should serve as consultive body to ministry.
6 Relation with hospitals,universities,specialist associations: Propose a clinical stream which is under specialist associations .AAnd an academic stream upgraded to research degree who remain within universities ,while the clinical stream after degree go for practice.The authors think this will avoid conflicts existing between MCI ,and National board ,increase the number of centers for training clinicians and raise standard of research.
7 Single window: Previous regulatory procedures included separate and independent inspections by MCI ,university and state governments.This resulted in a many-tiered system that lead to huge delays in obtaining approvals,and a single window for accreditation and approval of education is necessary
8 Standardised exams and validation: A common licensing examination for undergraduates and postgraduates to maintain uniformity of defined technical standards.All health professionals should maintain standards of professional knowledge and skill through regular re-validation.System of continued education and credits and regular reappraisals is mandatory
9 Transparency and accountability: To public scrutiny .A record of excellance in one;s field should be the basis of selection to proposed council .The authors propose the Nolan principles-selflessness,integrity,objectivity,accountability,openness,honesty and leadership-to form standards for holding public office and in public service.
The knowledge commission and Yash pal committee which examined higher education identified major lacunae and suggested an overhaul of the system.There is need for broad-based holistic education and dialogues between diverse disciplines and centers of learning .The regulatory councils chould act as facilitator and catalyst for creation of knowledge for society.
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.NCHRH can serve the goal of improving education in health sciences.It must ensure that education in health science fulfil a social mandate.It should provide a vision to improve healthcare delivery .


2 WHAT I UNDERSTAND :-
What I understand is that NCHER focus on policy and regulation and not on funds .Funding will be with a separate corpus with norms for block grants.The UGC,All India council for technological education and national council for teachers education will be thus replaced .By establishment of NCHRH as single apex body to oversee all education MCI will loose the power of control over medical colleges.The objections are raised already by Kerala,West Bengal and Tamil Nad governments as violation of federal principles.
What clauses do they object ?
1.A new university will get authorization by the NCHER .This is for quality control.
2.VCs appointed from a national registry.NCHER will suggest 5 nominees from a national list .There will be a collagium to recommend names of eligible persons.Quality of the person is to be considered .
Due to objectionfrom the three state Governments ,the reconsideration was done and the second clause on VC appointment was changed .But the first clause for quality was not changed.
Tamil nad Government has moved the supreme court for changing a single national common entrance test .
A national exit examination (screening test)for students graduating from Indian medical colleges is proposed.A national court for accreditation and national medical education and training board that regulate and accredit medical colleges ,prepare a list of the entire health sector,and regulate all streams of education in health sector is to be set up.
In an attempt to make India a global knowledge hub,a draft law for “innovation universities” made and these universities enjoy total autonomy in appointments ,collaborations,and resource generation.The 14 universities selected will be not-for-profit legal entity.Eacg university will be built around a theme or subject ,these universities will enjoy total autonomy in appointments ,nomenclature of degrees.Open to all nationals ,genders,ethnicity,disability ,provided at least half the students admitted to any programme are Indians.There is no mention of caste based reservation.(HRD Ministry) Each university has to endorse a university endowment fund but have the freedom to receive donations ,contributions from alumni,and other incomes as long as 80 % of the annual income is used for development of research and infrastructure.The university will be a not-for-profit legal entity and no part of the surplus revenue will be invested for any purpose except the growth and development of the university.
Many existing universities could be truly innovative if only the autonomy in the draft bill was extended to them.The clarity of seat allotment,reservation for Indian students have to be more transparent.Innovation universities are private institutions.HRD ministry can give grants to develop them .In that case the President will be the visitor and government would have a larger role in their functioning.
Each uty has an independent board of governors empowered to discharge all functions by enacting statutes to provide its administration,management,and operation.The board will delegate powers to academic board,headed by VC that will perform financial,management and administrative functions including appointments and collaborations .The board of studies will specify programmes of study.The faculty of knowledge,manpower assessment to study and assess through research trends in emerging fields of knowledge of relevance and the research council that will interface with the research funding organizations ,industry and civil society .
The government will protect maintain and utilize the publicly funded intellectual property for which the title vests with it and it can give directions for prohibiting or restricting the publication of information to any person or entity which it considers necessary in the interests of the country.The income or royalty arising out of publicly funded intellectual property will be shared by the innovation university with the intellectual property creator in accordance with the peovision.
The 14 universities are expected to set benchmarks for excellance for other institutions of higher learning through”pathbreaking research and promoting synergies between teaching and research”.Each university will stand for humanism ,tolerance,reason and adventure of ideas and search for truth.”It is expected to attempt to provide a path for humankind free from deprivation and seek to understand and appreciate nature and its laws for the well-being of the people.
3.A FEW CLAUSES IN THE UGC COMMITTEE REPORT 1992 (DOCUMENT FROM NATIONAL INSTITUTE OF EDUCATION,PLANNING AND ADMINISTRATION ) :-
This I quote for clarifying the point that what the nation suggests is to solve the problem for all ,in an amicable way and if there are any loopholes for injustice,we as citizens can point out them and try to help solve them .
Page 2 item 7:- Augmenting resources (private institutions are encouraged by this) given in detail in chapter 9
Item 9 mentions increasing the resources to meet requirements
Item 10 financial assistance to needy students –frees tudentships,scholarships,student loan for equity in education in detail in chapter 10.
Page 4 .1.11.1 :- At present state funds are mainly for salary,allowances(nonplan) and campus expenditure ,local ,municipal services and not much for plan,academic excellance etc
Page 5:- Two problems noticed:- functional autonomy is not possible in financial decisions by universities .The dual administration and dual funding in some universities ,delay in getting them in time etc
Page 6 has given a few INTERIM Recommendations :- To generate a fund ,keep it as separate fund for achieving objectives of university .To give incentive grants –as matching grants-by UGC to institutions who generate own resources.And 100 % income tax concession on all endowments/contributions and to donors sponsoring selected research projects
Page 7 : Increase the burden on those who can afford financially and from that income provide for poorer sections- tuition waivers,scholarships,etc .
Essential maintainance,development requirements from state itself.Accountability in terms of quality,cost consciousness,costeffectiveness to be achieved.
The committee e noticed that nonplan expenditure is always more than plan expenditure .The universities are struggling to maintain the expenditure and fail to achieve quality.They should be designed to promote quality,efficiency,autonomy ,accountability and relevance.
Equity and social justice (page 17):- Direct support to poor deserving students –Indian situation _1.We have to preserve and promote our national integration
2.Achievement and quality performance comparable to international standards
3 Equity and social justice to poor should be safeguarded
The newly emerging beneficiaries from secondary education should be able to afford an access to higher education (the vulnerable group).
Page 18:- Universities are an
1 Essential input for meeting manpower requirements for national development
2 Critical input to ensure social justice and equity ,upward mobility
3 Input for improving quality of life –higher level of integrated knowledge available to widen base of population and preserving national and cultural heritage
Page 23 :- Scholarships and fellowships should not be reappropriated to any other head of account .Plan fund should not be diverted to nonplan fund either should be added to this clause,I think.
Page 27 : 4.15.The existing system had lead to practices in which an efficient institution is punished and inefficient institution is securing more grants and support .Therefore,universities(as well as people) become more inactive ,no new programmes,no internal generation of funds,no costeffective efficient management –the committee noted .
Page 32:- What have the universities to say ?
1.Delay in sanctioning schemes
2.Irregular release of funds
3.Inadequate delegation of powers I implementation of plan schemes
Cha 5 is on negotiated funding based on last years expenditure
Chapter 6 is proposal for future funds .What are these proposals in 1992 ?
6.5.1:- An internal academic audit system to determine needs and scope for new courses of study(page 39)
6.9.1V- Specified discretionary fund with the VC for promoting excellance in teaching and research without incurring any recurrent liability .(page 42).This is the reason why the quality of VC was specified by the new innovation bill I guess.If the VC is not of excellent character ,what happened with IMC will be repeated and money /funds may be misused .
Chapter 7 page 47 .:- 7.9 Presentation of students in terms of income groups (so that all weaker sections get access to higher education) is a welcome decision.For this allows analysis of income pattern of parents and based on this the support system to be collated and indicated (7.8)
It is interesting that the committee had anticipated resistance from the university community ,in advance (7.16 page 49) and says as in any departure from the past practice this is usual .
Nature of activity of uty/student strength/student-teacher ratio-teaching-nonteaching staff ratio ,stage of development of institution all considered in giving grants .
page 67 says Indian uty system is based on uty system of Britain . I beg to defer ,since it is the other way round .The value system of Indian university system (palkalai kazhakam /gurukula) was the model for British universities of early period.Indian UGC act was formed in 1956 but in UK the till 1980 no audit standards were established .(8.6) and after 1979 election a regulation of public life resulted in an academic standard group,an academic audit group and a university funding council (the successor of UGC )in UK .Joining with UGC ,in consultation with it,CVCP thematically based efficiency studies were designed (8.6.2) and in 1983 the standard of British university were fixed.
Selfdirected exercise by each individual/institution is the best internal audit (I call this a personal and practice development plan ) and for external audit a Guru/a sabha /samithi (committee/councils in modern sense) are set up. Accreditation and audit unit should have in its purview study alone and research is not under its control in UK .page 72(8.14)mentions performance indicators given by Mridula Sharma.
Chapter 9 is on income generation and utilization:-
As I have described the ancient university system of India(see history of Valabhi/Nalanda and other universities of vedic and Budhist India ) primary ,secondary education and care(patient care) should be entirely free or in certain cases with minimum fee /concession.The tertiary higher education and tertiary care institutions can collect fee from the rich and give free service to poor .
Beneficiaries from the first two sectors(students/patients) should get equal access to all sectors is the idea behind this suggestion .How is this possible ?One has to make internal and external audit for efficiency and excellance at each step .
What the 1992 report suggest is given below for generation of income by universities(page 78)
1.Fee from higher income student population .Keep this as a separate fund .Utilise for deserving low income students who prove merit in the previous sectors .Also for betterment of quality of institution to reach international standards
2.Rent out facilities like auditoria,classrooms,computer service,playground,guesthouse,hostels,lawn,mess etc
3 Individual departments to design programmes and short term courses of study.Thus generate resources without adverse impact on main academic activities.These units can retain a substantial amount so earned to support their main academic activities
4.Endowments,contributions,large investments,for academic and infrastructural development
5 Sponsors for research .May be state or central government agencies,public or private sectors,industries etc .These projects proposals should incorporate allocations for reimbursements for staff ,facilities and infrastructure support .Use for strengtheneing infrastructure.
6. Consultative mechanisms: Institute and members as a whole (not management alone) –faculty,students,alumni,nonteaching staff have representatives in this
7.Incentives to inculcate and implement measures –UGC support,encouragements as positive incentives and grants (page 79)
Page 80 (9.23) asks to have a separate fund for keeping high standards of excellance .
9.24 A part of it kept for building up a corpus fund ,the interest of which is for support activities of uty
9.25 a part goes to needy students and for academic improvement
Chapter 10 enumerates the existing financial assistance for scheduled cates/scheduled tribes .
10.2 : Department of welfare gives tuition fee and living expenses for scheduled catses/tribes .But there is delay in getting the amount .UGC suggests the advance grant to be given to uty in April itself (calculating the previous year expenditure and adjusting the amount at final stage of payment ) so that students and uty will have no problem.
10.3 .JRF has a 10 % cut off marks for SC/ST students
Also through open selection without qualifying examination they are being enrolled for higher education seats.
10.4 Bookbanks are functioning for the weaker sections of students
10.12. Of the weaker sections 10 % of entire student population of uty is from economically poor weaker sections.The rest study with concessional rates based on merit .
10.13 Freeship schemes
10.14 existing loan schemes
The newly generated fund is for reducing the financial restraint on state and public fund and make the stronger(financially) sections of society share the funds for the sake of weaker sections and make equity come true from a national point of view .
This is what I have understood ,being part and parcel of Government medical college (teaching and practice )and part of a private institution of excellance which take money from rich and try to help the poor/deserving .The problems of public sector funding and the problem of equity when privatization of higher education happens ,are thus taken into account by the UGC committee (which report I read in 1995 ) and I think it is these recommendations which the current Loksabha has passed as the bills ,as mentioned in the Hindu .
The aims are thus understood.To put it into practice all citizens,all institutions should be willing . It is not laws or committees and recommendations which we lack.It is the right attitude of national integration,and of duty consciousness,a right attitude to achieve personal,institutional,professional and national excellance as a responsible human being which each and every one of us should cultivate.No political party,no religion ,no other sectarian interests or personal selfish interests should bar that ultimate aim of a purely sathwik personality of excellance as Charaka ,our ideal Vaidya justly pointed out.Make us achieve that upward journey to excellance as a single united nation .