This blog post is part of a multi-part series. Our previous posts 1, 2 covered the salient features of the National Medical Commission Act, 2019 (NMC Act) where we highlighted some issues arising out of the same.
The NMC Act has some interesting aspects that relate to Community Health Providers (CHPs). We attempt to shed some light on this proposal.
Community Health Providers
The NMC Act, under Section 32(1) provides for granting of a limited license, "to practice medicine at mid-level as Community Health Provider to such person connected with modern scientific medical profession who qualify such criteria as may be specified by the regulations". However, it also clarifies that the limited license granted under Section 32(1) shall not exceed one-third of the total number of licensed medical practitioners. Secondly, the scope of practice of CHPs has been limited and they can prescribe specified medicine independently, only in primary and preventive healthcare1. It has been clarified that in any situation other than primary and preventive healthcare, they may provide medicines only under the supervision of medical practitioners.
The Rationale Behind Introduction of this Provision in the NMC Act
According to the "FAQs on National Medical Commission (NMC) Bill 2019", released by the Ministry of Health and Family Welfare2, India has a doctor-population ratio of 1:1456 as compared to the WHO standards of 1:1000. Furthermore, the country also faces massive disparity in distribution of doctors practicing/ willing to practice in the urban and the rural set up, with the urban to rural doctor density ratio being 3.8:1. Consequently, most of the rural and poor population in the country is bereft of quality healthcare services and is often exposed to practices of unqualified and unlicensed health care professionals or quacks as they are usually referred to.
As noted in the Ayushman Bharat initiative, which was proclaimed in Union Budget of 2019, 1,50,000 mid-level healthcare providers would be required in the next 3-5 years to tend to the Indian population and provide comprehensive primary and preventive healthcare. It will take 7-8 years to ramp up the supply of doctors3, therefore, in the interim, the concept of CHPs has been introduced with the primary objective of filling up the vacuum that is currently existing in the country in terms of adequate healthcare practitioners, and to ensure widespread reach of basic healthcare to the farthest and most under privileged populace of India. This was in sync with several such programs, which have been introduced globally with the aim of addressing the dearth of human resources in the healthcare sector4 and have shown positive results, especially in low and middle income countries.5
Previous Instances when Concepts Akin to CHPs were Introduced
Concepts akin to that of CHPs were previously introduced in several states such as Chhattisgarh, Assam, West Bengal, Maharashtra and Karnataka6, primarily to meet the disparity between the number of patients and healthcare practitioners. The most notable and recent of those are the Rural Medical Assistant (RMA) in Chhattisgarh and Rural Health Practitioners (RHP) in Assam.
Owing to the shortage of doctors in rural areas, the Assam legislature had enacted the Assam Rural Health Regulatory Authority Act7 (ARHRA), which came into effect on September 18, 2004. The law envisaged a diploma in rural healthcare and medicine8. Furthermore, in pursuance to the ARHRA, an institute for training was also established at Jorhat. Five batches of students were granted the diploma under the said legislation and given employment by the State. However, the constitutionality of the ARHRA was challenged by the Indian Medical Association (IMA) in a writ petition before the Guwahati High Court.9 The Court vide a judgement dated October 30, 2014, struck down the ARHRA, terming it unconstitutional. Further the Court went on to state that:
"...There is no check and balance for the rural health practitioners...As a court we cannot say whether the so-called diploma-holders would be competent to function as doctor unless they are so declared and certified by the Indian Medical Council... To allow the diploma-holders to function as rural health practitioner in the field of allopathy without judging and gauging their competency by the competent authority would have disastrous consequence in the rural healthcare, and to permit such., diploma-holders to practice in the field of allopathy in rural areas without a proper certification by the Indian Medical Council, would not only be bad in law but would have a deleterious consequence in the matter of rural health..."
The matter is currently in appeal before the Supreme Court.
Upon its formation, the State of Chhattisgarh faced an acute shortage of trained healthcare providers. In order to fill up the vacuum in the healthcare sector, the idea of a 3 (three) year diploma course for training healthcare practitioners was conceptualised by the then Chief Minister of the State.10 Thus, the Chhattisgarh Chikitsa Mandal (CCM) Act was passed, which provided for the formation of the CCM, which was charged with approving and regulating the 3 (three)-year course. However, the CCM Act faced severe opposition as the course offered was called 'Practitioner in Modern Medicine & Surgery'. There was concern over the usage of the term 'modern medicine' and 'surgery' in the title given to the graduates of the diploma course11. The IMA was concerned that such a title would be misleading, give overarching powers to such diploma holders, lead to the dilution of the medical practice in the country. The opposition to the name led to the same being changed multiple times. Finally, the name of the course was changed to 'Rural Medical Assistants' (RMAs). This title was accepted by the medical community and the student community as the said policy called for the posting of RMAs under the supervision of a Medical officer. This addressed the concerns of IMA to an extent as it did not allow the RMAs to practice independently. Moreover, the students were appeased as they got government employment.
IMA's Discontent with the CCM Act and the Diploma Course Thereunder
The IMA viewed the idea of a 3 (three)-year course as dilution of the standards of the medical profession. Not surprisingly, therefore, it filed a case questioning the legality of the course almost immediately after the CCM Act. Even though there was no verdict in favor of the IMA, the Government's engagement with the 3 (three)-year course was almost exclusively dominated by it having to survive this legal challenge and to find the legal space to start and continue with this course. The three major areas of contention were the syllabus, the exact identity of the graduating students, and institutional provisions related to standards and the transparency of process – especially admissions, hiring of faculty and maintenance of quality in certification.12
Analysis of Section 32 of the NMC Act
There is widespread discontent in the medical community with regard to the introduction of NMC Act13. One of the most important points of discontent is regarding the appointment of CHPs under Section 32 of the NMC Act.
Criterion for granting license and practice
Similar to the contentions that the IMA had against the concept of RHPs, the vagueness of the provisions in the NMC Act is of primary concern. Section 32 of the NMC Act does not clearly provide any criterion on the basis of which the license to practice medicine will be granted to such CHPs. There is no clarity whether such license to become a CHP is to be granted after completion of a diploma course akin to RMA or RPA. Section 32(2) of the NMC Act says that the conditions and circumstances of practice will also be determined by regulations. Thus, at present, there is no clarity regarding the concept and characteristics of CHPs. The medical community is also in the dark about the qualifications based on which the license will be granted to a CHP, leading to widespread discontent on their part.
Terms used in the legal provision providing for CHPs
A perusal of Section 32(1) of the NMC Act brings to notice the usage of the phrase, 'may grant limited license to practice medicine'. The definition of 'medicine'14 under the NMC Act has a wide ambit and includes approximately the entire scope of medical practice and thus, introduction of such a term in the scope of work of a CHP could be highly misleading and confusing. Without a well-defined and strict scope, CHPs could harm the healthcare mechanism of the country as under-qualified medical personnel would end up practicing in place of qualified medical practitioners, thus leading to quacks dominating the medical profession. We must also note that it was terms such as 'modern medicine' and 'surgery', which caused discomfort to the IMA against the diploma course introduced in Chhattisgarh, causing subsequent legal battles between the IMA and the State Government. Eventually, as a result of the legal battles, the State Government was forced to revise the name of the diploma course.
Practicability of restrictions as given under Section 32(3) of NMC Act
Section 32(3) of the NMC Act provides that though a CHP can practice independently in primary and preventive healthcare, he may prescribe medicine under other circumstances only under the supervision of a medical practitioner registered under Section 31(1) of the NMC Act.
Though the said provision is provided by law on paper, the implementation of the same is difficult. A report15 on the RMAs in Chhattisgarh notes that in practice, in many cases, especially in remote areas, the RMAs had to function independently as no medical officers would join them.
Thus, though programs like CHPs help to fill in the deficit of medical professionals in the country, there is a strong possibility of the same causing dilution in the medical practice if it is not heavily regulated.
1 Article 32(3) of NMC Act.
5 Ibid; Hart JT. The inverse care law. Lancet 1971; 1 (7696): 405 412.
6 It is to be noted that though the states of Maharashtra and Karnataka conceptualized courses which provided for diplomas for roles akin to CHPs the same could not be implemented. The State of West Bengal though had implemented such a diploma course. The notification had been published in Calcutta Gazette, Extraordinary, Part 1, No. 787, dated October 15, 1980.
9 2014 SCC ONLINE GAU 605.
13 https://www.thehindu.com/news/national/andhra-pradesh/doctors-up-in-arms-against-nmc-bill/article28776477.ece; https://www.news18.com/news/india/doctors-unhappy-with-nmc-bill-say-new-law-only-complicates-regulating-medical-education-2246273.html ; https://ehealth.eletsonline.com/2019/07/ima-opposing-national-medical-commission-bill/.
14 Under Section 2(j) of the NMC Act, 'medicine' means modern scientific medicine in all its branches and includes surgery and obstetrics, but does not include veterinary medicine and surgery.
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