Report of the Department-Related Parliamentary Standing Committee On Health And Family Welfare Sixtieth Report On The National Commission For Human Resources For Health Bill, 2011 (Ministry Of Health And Family Welfare) (Presented To Hon’ble Chairman, Rajya Sabha On The 30 Th October, 2012) (Forwarded To Hon’ble Speaker, Lok Sabha On The 30 Th , October, 2012) – Rajya Sabha Secretariat New Delhi
The Committee notes that the medical education and healthcare under AYUSH has not been brought under the Bill. The Committee, therefore, heard the views of the Secretaries of Departments of Health and Family Welfare and AYUSH. Both the Departments of Health and Family Welfare and Department of AYUSH desired to keep the Indian Systems of Medicine and Homoeopathy out of the ambit of the present Bill on the ground that the Allopathy and the Indian Systems of Medicine and Homoeopathy are completely different and the latter needs focussed attention for proper development.
It was, therefore, proposed to be kept on a separate footing due to the apprehensions that if they were brought under one Commission, the focussed attention of the AYUSH may be lost. It was also brought to the notice of the Committee that a separate Department was created in 1995 for Indian Systems of Medicine and Homoeopathy to give focussed attention and later it was named as Department of AYUSH in 2003. A separate policy known as ‘National Policy on Indian Systems of Medicine and Homoeopathy’ was also formulated in 2002.
The Committee cannot understand the rationale behind having two separate overarching bodies for two different systems of medicine within the country.
The Committee is of the view that there should be only one overarching body and all the health/medical professions should be brought under one single umbrella though with separate Councils.
The Committee, therefore, recommends that the Indian Systems of Medicine and Homoeopathy may also be brought under the jurisdiction of the National Commission for Human Resources for Health. The representatives of the Councils of the Indian Systems of Medicine and Homoeopathy may also be given representation in all the bodies, i.e., the Commission, the Board as well as the Assessment Committee so that their interests are well taken care of.
Other main points
The Committee takes note of the fact that even though it is more than sixty years since India attained independence, affordable healthcare and health education have been a distant dream for the common people of the country. Even though concerted efforts have been made by the Government, but due to substantial socio-economic and geographical inequalities, those efforts have not made the desired impact. The Committee expresses its concern over the acute shortage of qualified health workers including doctors in the country. It is constraining to note that as per 2001 Census, the estimated density of all the health workers (qualified and unqualified) in India is about 20 per cent less than the WHO norm of 2.5 workers (doctors, nurses and midwives) per thousand population. This shows the substantial shortage of qualified health workers in the country. The Committee also notes the disparities between the rural and urban areas in respect of the availability of health infrastructure. Even though there is a steep increase in the number of medical colleges in the country, the cause of the concern for the Committee is that a number of colleges that have been opened are not evenly distributed. This has resulted in distorted distribution of the country’s production capacity of health workers. The Committee also takes cognizance of the fact that the other health professions such as nursing, pharmacy, etc., are not in a promising state. The nursing education is also in a poor condition resulting in poor quality of the nursing professionals. Similarly, the nurses-doctors ratio in the country is only 0.8:1 as against the ideal ratio of 3:1. Adding to these woes is the criticism being made against some of the National Health Councils, leading to judicial censure on several occasions. The Committee, therefore, takes note of this background in which the Bill has been brought forward by the Government in the Parliament.
Taking note of the importance of the Bill and its likely impact on the availability of health professionals, health infrastructure and ultimately healthcare delivery for the common people of the country, the Committee took the views of a cross-section of the society and various stakeholders. The Committee feels that the need for reforms in health sector is long overdue so as to invigorate the health sector. But several stakeholders have raised serious apprehensions on various provisions of the Bill and effectiveness of various bodies that are proposed to be established under the Bill. In view of the apprehensions expressed by various stakeholders, the Committee, in its meeting held on 17 August, 2012, felt that the Bill, in the present form, cannot be recommended. The Committee, therefore, decided not to go in for clauseby- clause consideration of the Bill and to recommend to the Government to consider all shades of opinion and all the suggestions and bring forward a revised comprehensive Bill before the Parliament.
The Committee, however, makes the following general observations/recommendations to enable the Government to take necessary action at the time of revisiting the Bill:
The National Commission for Human Resources for Health, as proposed in the Bill, is mandated to take measures to determine, maintain and coordinate the minimum standards of and promote the human resources, in the disciplines of health education and training, commensurate with the requirement of such resources in different States and Union Territories. The Committee is aware that ‘Health’ is a State subject whereas ‘Health Education’ figures in the Concurrent List of the Constitution. However, the composition of the Commission gives no representation to the States. The Committee agrees with the viewpoint put forth by the State representatives that the States play a vital role in delivery of healthcare and medical education. States are well versed with existing medical education capacity and know their future requirements better. The Secretary, Department of Health and Family Welfare, during the course of his deposition before the Committee stated that he was open to giving greater representation to the States in the National Commission, the National Board and the National Evaluation and Assessment Committee. It is, in this context, that the Committee is of the considered view that a substantive role should be mandated for the States in the Commission. The Committee, therefore, recommends to revisit the institutions of National Commission, National Board and National Evaluation and Assessment Committee and give adequate representation to the States. Cooperation and coordination of the States is very essential for better provision of healthcare and health education in the country. Discussions may be held with all the State Governments before revising the Bill. Necessary modifications may, accordingly, be made in the Bill.
Some stakeholders favoured strengthening of the existing Councils rather than overarching body as proposed in the Bill. They felt that sufficient safeguards should be provided in the present Councils to ensure their transparent functioning and accountability to the Central Government and the Parliament. The Committee also took note of their concern that the present National Councils have been relegated to maintaining the Central Register only, in the Bill. There was also a mention that in the National Commission, National Board and National Evaluation and Assessment Committee, the representation of several professions has not been indicated. The Committee notes the concern expressed by the Councils that their autonomy and democratic set-up have been taken over under the Bill. The Committee feels that these apprehensions need to be appropriately addressed by the Government in the Bill. There is a need for clarifying all these concerns. The democratic functioning of the National Councils should be appropriately protected, even if they are brought under the overarching body. As regards the existing functions of the Councils, the Committee suggests that Councils may be given the powers to consider all the proposals as per the existing functions and after their due consideration, the three bodies proposed under the Bill i.e the Commission, the Board and the Assessment Committee may be given the power to take final decision in the respective matters. Besides, adequate representation should be given to all the professions in the proposed Commission, Board and Committee.
Some of the stakeholders expressed their apprehensions that there is no element of election in the composition of the Commission, Board and the Assessment Committee. The Bill provides only for the appointment by the Central Government on the recommendations of the Selection Committees. In fact, this has been objected by the State Governments also. The Committee desires, that the apprehensions of stakeholders may be considered by the Government while revising the Bill.
The Selection Committees proposed to be set up for recommending persons for nominations to the Commission, Board and the Assessment Committee have been questioned by some of the stakeholders. They felt that the selection process for the Selection Committees has been made very ambiguous stating that the Chairperson and Members shall be appointed in such manner as may be prescribed. The Committee agrees that this would lead to doubts in the minds of the people and this needs to be clearly spelt out. The Committee, in this regard, takes note of the Higher Education and Research Bill, 2011 in which composition of the Selection Committee has been clearly spelt out. The Committee recommends that a procedure on the similar lines be spelt out at the time of revising the Bill. The Committee also feels that the members of Selection Committee should be persons of eminence, preferably from the medical field. Besides, the Committee also recommends that there should be only one Selection Committee for all the three bodies.
The Bill provides that the Chairperson or a Member of the National Commission/National Board/National Evaluation and Assessment Committee can be removed by the Central Government at its pleasure which is very ambiguous provision and susceptible to misuse whereas the Higher Education and Research Bill, 2011 provides that the Chairperson or a Member of the National Commission for Higher Education and Research can be removed by the President. The Committee feels that a similar provision may be incorporated in the present Bill. The Committee recommends that adequate safeguards may be provided in the Bill so that the Chairperson and other Members of the Commission, Board, and the Assessment Committee are able to discharge their duties and responsibilities in a fair and objective manner.
It has been brought to the notice of the Committee that though the Bill seeks to abolish the National Board of Examinations (NBE), it fails to define how the existing streams of health education run by the NBE are to be preserved and promoted within the ambit of the Bill. The Committee is given to understand that the NBE has provided standardized examination for post-graduate courses across the country and public sector hospitals like Railway Hospitals, Armed Forces Hospitals and some private sector hospitals like Sir Ganga Ram Hospital, Shankar Netralaya, etc. are participating for the post graduation courses. It has been impressed upon the Committee that India is very short of specialists and the NBE provides an opportunity beyond the medical colleges to train the specialists of higher order. The Committee agrees that the NBE performs very important functions and the post-graduate medical education of the highest order is being standardized by it, and if this stream disappears, it is going to affect the specialists, who have been awarded degrees so far. The Committee, therefore, recommends that the above apprehensions be adequately addressed and precise and explicit provisions be made while revising the Bill to protect the existing streams of PG education run by the NBE.
The Committee also takes note of the apprehensions expressed before it about a potential conflict of powers between the Commission, the Board and the Assessment Committee due to lack of clarity regarding the powers of the three bodies. One of the apprehensions was that the Commission gives permission for new courses under Clause 17 of the Bill whereas Clause 30 gives an impression that the Board is fully empowered to recognize new courses and give accreditation to new courses. Similarly, it was also apprehended that there is conflict between Board and Committee regarding accreditation of Health Educational Institutes under Clauses 30 (2) (t) and 37 (1) respectively. The Committee strongly feels that there is a need to clearly demarcate the respective jurisdictions of the three bodies under the Bill.
The Committee also takes note of the apprehensions expressed by some of the professional associations like physiotherapy, dental hygienists, optometrists, occupational therapists etc. They expressed the desire to have separate Council for each of the professions. For example, Dental Hygienists Association felt that they are always relegated to the background and they do not get sufficient prominence. They also felt that their profession has not been appropriately represented in the Bill. The Committee feels that many new fields have emerged in the health profession but the new fields are yet to be granted the status of separate Council so as to ensure their better growth, regulation and standards. The Committee, therefore, recommends that their grievances may also be taken care of and separate Councils may be provided for them, wherever feasible.
The Committee takes note of the provision in Clause 17 (6) which provides that where no order on establishment of institution for imparting health education or a new course of study has been given by the Commission for a period of one year, the same shall be deemed to have been approved by the Commission in the form in which it has been submitted. The Committee expresses its serious doubts on this open-ended clause. The Committee feels that this clause is susceptible to misuse by allowing backdoor entry of health institutions or a new course of study by stalling the decision for one year, which would automatically be treated as approval. The Committee recommends that this provision may be made more stringent and sufficient riders and safeguards may be provided in the clause.
The Committee is also of the view that there is no mention about the Medical Research in the preamble, powers and functions of the Commission nor has been defined under the definition in Clause 2. It has only been mentioned in Clause 30(1)(a) under the powers and functions of the National Board of Examination stating that it is one of the functions of the Board to maintain standards of Health Education and Research. Health Research is covered under the Higher Education and Research Bill, 2011 also. The Committee has noted that in the Higher Education Bill, 2011, Agricultural Education and Research has been kept out of its purview. A comparative perusal of contents of the provisions pertaining to jurisdiction and functions of the Commissions proposed under both the Bills reveals that both the Bills have identical jurisdiction and functions on various aspects of Medical Education and Research. Under such circumstances overlap and conflict of jurisdiction is inevitable. Wherever there is overlap and conflict of jurisdiction between more than one agency on a particular subject, the ultimate sufferer would be its objective i.e. development of medical education and medical research. The Committee is not in agreement with the Ministry’s contention that Health Research requires a forum like National Commission on Higher Education. There is a separate department for Medical Research mandated with the responsibility of development of various aspects of Medical Research and coordination between various National and International Agencies engaged in Medical Research. In the given circumstances, the Committee is of the opinion that it would not be appropriate to keep Medical Education and Medical Research under the jurisdiction of more than one Agency and Ministry. It would not serve any purpose and rather it would hamper its development. The Committee, therefore, strongly recommends that both Medical Education and Medical Research should be brought under the purview of the proposed National Commission envisaged in the Bill. The Ministry may appropriately address this issue while revising the Bill.
The Committee notes that though Health Educational Institutions, Health Institutions and Health Education have been mentioned in the Bill, but Health Education has not been defined while Health Educational Institution or Health Institutes have been defined. The Committee desires that this may be amply clarified. The Committee also desires that health education should be replaced by medical education because it is not the Health Educational Institution, it is Medical Educational Institution which imparts various kinds of medical education. The Committee, therefore, recommends that Health Education, Health Education Institutions/Health Insitution may be replaced by Medical Education/Medical Educational Institutions/Medical Institutions whereever they appear and Medical Education may be appropriately defined.
Similarly, distance education system as has been mentioned in Clause 2(r) is also not acceptable to the Committee. The Committee feels that Medical Education should not be imparted through distance education mode and it should be a regular course.
The Committee has received several suggestions from various stakeholders in the form of written representations, written submissions as well as oral evidence. The Committee has dealt with some important suggestions made by various stakeholders and appended all the memoranda/written submissions to the Report. The memoranda/written submissions received from various persons/bodies have been sent to the Ministry for comments. The issues raised by various persons/bodies in the memoranda and the written submissions and the comments of the Ministry are appended. Some of the stakeholders have proposed amendments to various provisions of the Bill. The Committee recommends that the Ministry of Health and Family Welfare may carefully examine all the suggestions made by various stakeholders in the written memoranda, written submissions and oral evidence and also the recommendations made by this Committee while revising the Bill.
All the apprehensions made by various stakeholders may be appropriately addressed. If need be, the Ministry may hold another round of discussions with all the stakeholders before finalizing the fresh Bill.
The Committee, accordingly, recommends that the Ministry may withdraw this Bill and bring forward a fresh Bill after sufficiently addressing all the views, suggestions and the concerns expressed. Before finalising the fresh Bill, the Ministry may hold discussions with all the stakeholders including the State Governments.
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