Part 3: The Making of the Health Professional — Changing Policies in Health Professional Education and Professional Regulation, And the task before Peoples’ Health Movements

The National Medical Council Bill- 2019

A Jan Swasthya Abhiyan Policy Brief (up-dated 10th August, 2019)

The need for a new act replacing the Medical Council Act is no doubt of utmost importance. Unfortunately, the National Medical Council Bill of 2019, now an Act, has failed to identify and address the main problems of the earlier council, and by rushing through this current bill using its brute majority, it has created considerable new dangers. Many state governments have also opposed this Act.

In this note we share with the public some of our major concerns with regard to this bill:

Loss of Federal Structure

Firstly, there is an almost complete abandonment of the federal structure and an obsession with centralizing every detail of both medical education policy and professional regulation, and all the means of implementation.

Governed by the bureaucracy:

Further, even at the centre the powers are immensely concentrated in the bureaucracy- with only a very token role for a limited number of 5 elected members. The representatives of the state medical councils elect these 5 members. The Commission has totally 25 members. All the other commission members are nominated. Search committees for key posts are also largely nominated by the government of the day. Not satisfied with this, the government arms itself with even more powers to give instructions to the commission on policies or overrule any policy made by the commission.

States- Not decision makers, but advisors:

There is a Medical Advisory Council, whose only role is to allow members to voice their views. States are represented in this by a government nominated representative specified as the Vice-Chancellor of the state’s Medical university (or equivalent) and a member nominated by the state medical council. This downgrades the state role from decision-making to consultative. Even on providing this limited space for consultation there seems to be high degree of risk-avoidance since peculiarly all members of the commission are also made members of the advisory council!!!

Centralization and Institutional Capacity:

Centralization and micro-management are also inherent in the scope of the commission since it has powers to make rules and regulations for almost every operational detail. It would need an incredibly high level of institutional capacity in this central institution to administer such a mandate- and nothing that one has seen of central ministries and institutions would give us the confidence that they can do so. A humbler and more honest estimate of their own capacity by the central government, would have allowed for a greater role to states within a broad framework set by the national commission.

Open doors to private sector

Despite its omnibus mandate, on one aspect the Commission is curtailed. It can at best “frame guidelines for determination of fees and all other charges in respect of fifty per cent. of seats in private medical institutions and deemed to be universities.” Implying that for 50% of seats there would be no regulation whatsoever. Even for this 50% there are no indications of what would be principles of fee decision. One of the more retrogressive steps in this bill is that it opens the door to ‘for-profit entities” for the first time, and in the current context this largely implies opening the gates for the corporate sector. The obligation of providing access and affordability to under-serviced populations and aspirants gets no mention. These are just off the agenda. The aim of this policy is only within a highly privatized sector, how government can be seen to be concerned with the problems of quality of education.

Quality Assurance as Common National Examinations

For assuring quality, there is only one idea, another great centralizing one, the common national examination, one for entry into the MBBS course (National Eligibility cum Entrance Examination- NEET) and the other for exit. (National Exit Examination- NEXT) The exit examination is the examination for the license to practice as well as the examination for entry into Post-graduation courses.

The NEET Problems

There are problems with both. As an entry test into the MBBS course (NEET) it does not help prioritize suitable candidates for under-served areas — which is a great necessity considering the highly skewed availability of human resources. It does not recognize the limitation of the MCQ format and why performance in this within a timeframe requires skills and practice different from what it takes to understand a subject or write the usual examination. It thereby boosts the coaching industry and shifts the measure of merit towards the wealthier students who can afford such coaching… There are powerful arguments why states prefer to hold such common entrance examinations at the state level. Some 15% of seats can be surrendered to a central pool for which a national examination would be relevant. There is an even stronger case for going only by school leaving marks with standardization of marks across different boards.

The NEXT Problem:

As an exit examination, the MCQ format is even more limited since it does not test skills and patient interaction. Also, a final year student passes through different subjects in phases- and combining all into a single examination does not help. It will also act as a barrier against innovation and improvement. As an entrance examination into post-graduation, both sets of problems as described for NEET and for exit examination apply. Along with some newer ones.

Four Boards- but autonomous?

The NMC mandates four autonomous boards- (a) the UG medical education board, (b) the PG medical education Board, © the Medical Assessment and Rating Board and (d) the Ethics and Medical registration Board. The separation of these functions is welcome and potentially a step in the right direction. But there is nothing to indicate how these are autonomous and how each of these Boards would have the capacity to do what is required of them, and how these would retain even a minimum of internal democratic functioning. The notion, that these four functions can be carried out across the country, by four five-member teams situated in Delhi. To solve this problem for the Medical Assessment and Rating Board the bill state that the Board may “hire and authorize any other third-party agency or persons for carrying out inspections.” The main problem with these boards is the way they completely undermine the state’s role.

Corruption Neutral:

One big reason for the new act, and for repealing the earlier act is corruption. But there is nothing in this bill that gives anyone the confidence that corruption would reduce. The shifting from board members and medical experts to third party agency is more likely to change the form of corruption than eliminate it.

Ethics or Registry: Where is the capacity?

The Ethics Board function combines with medical registry- though these are very different skill sets and different institutional requirements. The only overlap is that it could be easier to remove the name of a person debarred on ethical grounds from the medical register. Nowhere is there a recognition of what it takes to maintain a live register or identify those without a registration who are in practice- and what would be the mechanism by which this is done. The requirements of the ethics function of this board is not only understated, there is not enough on what it covers, and how these functions will be managed.

Surprise Inclusion: Community Health Providers:

The other major new inclusion in the bills is the clauses related to community health providers. To quote:

“The Commission may grant limited licence 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;

Provided that the number of limited licences to be granted under this sub-section shall not exceed one-third of the total number of licenced medical practitioners registered under sub-section (1) of section 31.

The Community Health Provider who are granted limited licences under sub-section (1), may practice medicine to such extent, in such circumstances and for such period, as may be specified by the regulations.

The Community Health Provider may prescribe specified medicine independently, only in primary and preventive healthcare, but in cases other than primary and preventive healthcare, he may prescribe medicine only under the supervision of medical practitioners registered under sub-section (1) of section 32.”

To the Indian Medical Association this is one of the main areas of opposition. They label this a backdoor entry to quackery. The truth is that after poor progress in nearly ten years of efforts to put in place a mid-level care provider for the sub-centre level, there is a quick move to use the rapid movement of this bill to include that need. While one could argue that there is a need for such a provider at the primary healthcare level, most nations and some of the Indian states which have such a cadre in place, have a separate legislation to cover that cadre. Like there is for nursing, pharmacists, allied healthcare providers etc. To hurriedly pack that new agenda into this bill, without so much as a definition of what this term means, and no understanding of qualifications, conditional licensing measures, entry or exit, scope of work etc is to ask for big trouble. Even if that is not the intent of the government, the IMAs worst fears on this would come to pass- and a poorly qualified healthcare provider could get generated who would then proceed to enter to the highly competitive, almost predatory urban markets for healthcare.

Silences in the bill:

There are also important silences of the bill on a few critical issues. For example, though the effective grievance redressal mechanisms is one of the stated objectives, there is no further mention of it in the bill. The bill is also completely silent on kick-backs, commissions and other conflict of interests. The Bill has little mention of what happens to the state medical councils and how its mandate would get modified.

The Sub-Text: Professionals Role in Governance

Part of the reasons why this bill has so many flaws is that the entire history of the poor functioning of the medical council has been reduced to the inability of the medical profession to govern itself and this in turn is attributed (in the sub-text) to be inherent problem of the profession. Therefore, it is assumed that the moment such professional control is removed or diluted, the problems would go away. To some extent the medical professionals in the past medical councils brought this on itself- by not only failing to check corruption and poor ethics, but often becoming seen as the source of such corruption and failing to even eject the leadership that was tainted by courts for such corruption. But that was not the only problem- nor even the main problem- and the solutions that this bill offers may act to worsen the situation. The failure to analyse or understand the other policy and systemic roots for problems like poor quality of education, corruption, ethical deficits, lack of live registers, failure to generate human resources that are appropriate to our needs all come together with an anti-professional bias to bring about a bill that satisfies no one, and solves very little.

The Political Context:

The overall political context of this bill is also important to note. The main thrust of government policy is to shift the government from the role of provider of healthcare services to purchasing it from private providers through insurance or partnerships. This is a form of privatization where public expenditure to pay for the healthcare of the majority is routed through private providers at terms where they can make a profit and monopoly control can be encouraged. However, the lack of regulation — both in private medical education and private medical care is making this very difficult. Studies are showing that private providers do not abide by contractual terms and that private educational institutions are overwhelming corrupt and of poor quality. Instead of seeing the roots of the problem in privatization, the government would locate the problem entirely in the profession and professional regulation. This brings out stiff resistance from medical professionals.

In conclusion:

Clearly it is important to educate and shape public opinion on the provisions of the Act, our concerns regarding this- where we agree with the professional opinion as articulated by IMA and where we differ, and what would be the alternative formulations on some of the key issues.

Through this Act the central government has captured and concentrated all powers for improvement of medical education, and of closing gaps in availability of medical professionals and of quality of medical education in itself, and they would need to be held accountable for these tasks.

In the coming years as implementation of this Act begins, the problems are going to show up more glaringly. Already the ministry has begun with asking for a three-year time to begin implementation of NEXT as a licensing examination. Sections of civil society which have fought for health rights, professional associations and all democratic forces would need to exercise the utmost vigilance, ensure timely public exposure of the limitations and introduce into public discourse, better options/alternatives that could address these problems.

Health Professional Education and the Draft National Education Policy:

There are three important challenges that any policy on healthcare education would have to address:

First and most important of these is the serious mal-distributions of healthcare professionals across the nation. The national commitments to achieving universal access to healthcare can be achieved only if there is a minimum density of doctors, nurses, and allied healthcare professionals in every block and district of the nation. Such a distribution of healthcare professionals is closely linked to policies concerning entry into educational institutions, the context and content of the curriculum, and the subsequent policies of public financing and organization of public health services.

The second important challenge is ensuring the quality of education, so that the young men and women who are churned out of these institutions have the knowledge and skills to make the right decisions and provide the right care. Healthcare in a service sector where due to information asymmetry and uncertainties in outcome, the service user’s ability to make the choice of provider, or even to judge whether the care received was appropriate and adequate is limited. Further in most contexts of private practice the providers own monetary incentives may not be aligned with the best interest of the patient. All this calls for a high degree of trust and the state must ensure that healthcare professional have the skills to deserve such trust.

The third challenge is also a dimension of quality of education- it is not just technical competence in terms of knowledge and skills that is required, but an attitude of caring. These are caring positions where the majority of practitioners would have to feel fulfilled and creative though acts of preventing illness, of taking care of the sick and even in supporting the dying. No doubt at all levels of care, some technical skills are essential, but what is equally important is the empathy that care providers have for those they care for, and the close bonding that is required between providers and the communities that are served, and the ethical values they have imbibed during professional education and practice.

The Draft National Education Policy, not only fails to address these challenges, it could actively worsen it. (Healthcare education finds place in the draft National Education Policy as one of the sub-topics of the chapter on Professional Education). -

In table 1 below, we show the highly skewed distribution of undergraduate and post-graduate seats per lakh population across the states. Those states which have the largest shortfall of doctors are also the states where the number of seats per one lakh population are less than the national average. The distribution within states is also similarly skewed. A similar skew in availability of seats and professionals can also be demonstrated for nurses and for many of the allied health professionals.

Given the fact that upwardly mobile urban youth from more privileged sections are the most successful in gaining entry into healthcare educational institutions, the increases in seats in states with relative surplus is only going to lead to unhealthy competition and lowered remuneration for doctors within a few of the larger urban areas. It does not lead to surplus doctors and nurses shifting to under-serviced areas. Bonds and other forms of compulsion for working in rural areas seldom work, and even to the extent they do, such professionals would not have the same level of empathy and bonding with communities as a doctor who would actively choose to work in such an area. In many nations across the world, preferential admissions for students from under-serviced communities and regions along with commitments and incentives to go back to these areas after graduation is what has helped most in closing such service gaps.

The National Education Policy is silent on how these huge human resource gaps by region, by state, by gender, or by more marginalized castes and communities would be addressed. The silence is not surprising since equity in access to healthcare education and access to healthcare can be achieved only though public educational institutions based on public financing and affirmative actions such as free or highly subsidized education to bring in suitable candidates from these regions and communities. The silence would however be consistent with an approach that prioritizes opportunities for private profit in healthcare education and the demand of more privileged sections to send their children to medical schools over the public needs for health care. Over the last two decades commercialization of healthcare education has been rapidly increasing, and now the majority of the institutions are in the private sector. Further the majority of medical and nursing seats need such high payments that much of the population is actively excluded from such education. This NEP exacerbates this problem. It gives permission to educational institutions to charge any level of fees- and commits them only to providing scholarships for a proportion of the students- a commitment that in practice would be almost impossible to enforce.

The terms of such market driven expansion of healthcare education have led to great loss of quality in the output- a fact that is almost universally noted and lamented. The policy quite correctly states that regulatory regimes under the professional councils were inadequate to the task, and had serious conflicts of interests but the solutions proposed are worse than the problem. The NEP calls of dispensing with the role of councils as regulator, but in its stead what it proposes is one huge centralized structure that will command all of higher education, all across the nation. The NMC bill has already done this for medical education. The proposal is now to extend this approach to all of healthcare education. It is unclear whether; any single central institution can ever command such a capacity, or needs to. Constitutional provisions today put educational standard setting in the union list but explicitly leave regulation of higher education to the states.

But the bigger problem is an almost exclusive reliance on common national eligibility cum entrance examinations (NEETs) at every stage, as the single most important strategy of all educational governance. The proposal assumes that common examinations for entry at the under-graduate level and the post-graduate levels are effective and seeks to transform the latter to also serve as a common exit examination, for licensing purposes. Presumably the two NEETs would be the most fair and transparent purely merit based measurements of quality which would cut across the divides of public and private, communities and regions. If the proposal to allow all professional students to do a common first year foundational course followed by a merit-based sorting into medicine, nursing and dentistry streams is taken seriously, that would probably add a third NEET to the pool. But the challenges of implementing such a streaming are so ridiculously high, that we need not get distracted into discussing it.

The NEET itself has been a basis of considerable criticism and it is now clear that it is a tool that exacerbates inequities and undermines the federal nature of educational governance. Protest is maximal in precisely those states, like Tamilnadu, where after a long process of discussion with different sections a working balance had been struck between the needs of different regions to access healthcare and the needs of different sections of the population to access the opportunities of healthcare education. Then and now 15% of the under-graduate seats and 50% of the post-graduate seats were given to all India quota. But for filling up the 85% of seats, another merit based, fair and transparent systems was devised by states, which was perceived as giving students from government schools, and more marginalized communities studying with state language as a medium, and unable to afford costly coaching session, a reasonable chance of getting selected. Even this had problems. But post NEET, students who are from schools following central, all India examination boards, and those going to costly coaching schools which have cracked the sub-text of these examinations have a much stronger advantage.

Similarly, at the post-graduation level, the state of Tamilnadu had a system in place, where graduates could to work in rural areas, confident of the extent of advantage it would give them for accessing post-graduation and governments had worked out how to fill specialists’ posts in all its district hospitals. The state also had chosen to invest in expanding postgraduate and super-specialization courses using their own budgets and made public service after qualification mandatory for those getting government education. But with a nation-level centralization of the examination process, and surrender of 50% of postgraduate seats and 100% of super-specialization seats to the central pool, the ability of the state government to find the necessary candidates has been seriously compromised.

Further private educational institutions are allowed to keep fairly high levels of seats in the management quota. And thus, any student seeking admission in a private medical institution and able to pay the high fees and with enough influence to get selected would qualify with much lower NEET cut-off score. This system not only continues but also is encouraged within the language of the policy.

All of this emphasis on nation-wide common examinations is presumably in pursuit of measuring merit in a manner that is blind to social and educational backgrounds- a sort of huge educational level playing field that encourages a competition among students where the only currency is objectively measured merit. But then in a bizarre Freudian slip, the text of the draft policy has this gem: “this exit examination will be administered at the end of the fourth year of the MBBS so that students are relieved of the burden of studying for a separate, competitive entrance examinations at the end of their residency period. With the entrance examination out of the way, they can spend their residency period acquiring valuable skills and competence.” (para 16.8.3, pg. 305) The true import of this is that the proposed measure of testing would not measure valuable skills or competence, even those which are learnt in the most crucial part of the medical curriculum- the final year of clinical training. De jure, NEETs are the only basis for measuring learning. But de facto, the national common examination is accepted as a barrier to learning. The only use that NEET then has is as a device for ranking and sorting students into an apparent hierarchy of merit with all its attendant privileges and to exclude the rest and justify the exclusion. Close to 1.47 lakh medical graduates appeared for the PG-NEET examination last year, of which only about half are considered to have passed and only about 27000 would get seats anywhere and of which a much smaller proportion would be affordable seats. The majority of those who ‘fail’ NEET would face frustration and guilt- all the more so because to get so far, they have had excellent academic careers and though by temperament, attitude, experiences and skills — and even knowledge they may be much better than those who made it. There are other unfortunate collaterals of this NEET defined hierarchy of merit. One, for example is that students who qualify with lower thresholds due to reservation quotas face discrimination which could get justified on this basis, though their work performance may be no less than the others. The recent tragic suicide of Dr Payal Thadvi was an example of this. The rich student in the management quota is however unlikely to face such a disadvantage.

This hierarchy of merit takes other forms. There is for example the proposal to phase out all diploma education in nursing, and make B.Sc the only nursing entry. Persons working in field situations would testify that not only is it impossible to close gaps in nursing cadre with only B.Sc nurses, there are many field situations where diploma nursing students are better suited. Similarly, a community health worker or a mid-level care provider is not an apology for not having a doctor. Rather they are the most appropriate care providers in that given context.

One curious inconsistency in the draft is a proposal for periodic renewal of licenses for nurses through some testing procedures- while there is no such clause for any other category of service providers- specialists, doctors, or other allied healthcare professionals who may need such on the periodic skill upgradation and re-certification even more.

On the challenge of creating healthcare professionals with empathy- scientifically competent, but also ethical, humane, caring, communicative, sensitive to concerns of equity, and social accountability, the section on healthcare policy is a non-starter. Which is surprising considering the almost poetic eloquence with which the importance of liberal education is set out in the introductory chapters of the higher education section. The introductory chapters posit liberal broad-based multidisciplinary education as essential for developing “critical 21st century capacities” and defines this as including not only exposure to humanities and social sciences but also an ethic of social engagement… (11.3.1. pg. 234–5). It calls for professional education to be “cognizant of larger social concerns, and develop a mindset of public service and cultural awareness” and promises that professional and technical education will not remain narrowly-focussed on technical expertise alone (see chapter 9, pg. 202). On specific strategy to achieve this that is proposed is that “the practice of setting up stand-alone universities for professional education will be discontinued,” as “the practice of setting up separate technical universities, health sciences universities, legal and agriculture universities in each State to affiliate colleges offering professional education in their respective disciplines, has resulted in deepening the isolation further”. “All institutions offering either professional or general education must organically evolve into institutions offering both seamlessly by 2030. (pg. 301)”. It particularly condemns how in healthcare; education is offered largely in silos of individual subjects and separate from general higher education. Although the effort in professional education has been focused mainly on making students ready for ‘jobs’, the outcomes, in terms of employability, leave a lot to be desired. (pg. 293. Chapter 16).

None of these laudable values seem to inform or animate the authors of the healthcare education section. There is nowhere in the text of this section, any attention given to how we produce healthcare professionals who care, who feel for the individual and society. And whatever space emerges for such character building locally or spontaneously, would be swallowed up by the waves of MCQ based national examinations that the student would have to face. The proposals in this section are all examples of what is declared as wrong with professional education in the earlier section. NEP paragraph on allied healthcare providers states that a “syllabus will be standardised pan-India, drawn up in conjunction with Health Universities and State Allied Health Sciences Boards, … These training programmes will be hospital-based, at those hospitals that have adequate facilities, including state-of-the-art simulation facilities, and adequate student-patient ratio.” In this policy statement, the health university is retained, and the vision of the educational institution has given way to a description of a corporate hospital. Further some of the jobs mentioned as priorities are very narrowly based on current corporate healthcare industry requirements (e.g. general duty assistant), and more broad-based skills like pharmacists and counsellors find no mention. Almost none of the essential public health skill merits mention.

As a concession to the imperative of regional equity in the creation of new health education institutions, the policy puts forth a proposal “to upgrade the nation’s 600 district hospitals to become teaching hospitals, “to train doctors, nurses and allied healthcare professionals.” But are district hospitals so easy to transform into educational institutions? Whatever happened to all those brave words about liberal education and the multi-disciplinary university? It is one thing to ask for district hospitals to be upgraded to tertiary care hospitals and linked to university based medical colleges. Quite another to talk of upgrading district hospitals into teaching hospitals “by investing in infrastructure” and “stationing adequately qualified teaching faculty”. A proposal to identify districts with major HR shortages and link these with medical colleges and healthcare institutions which are part of public universities providing subsidized or free education with affirmative policies to bring in more candidates who relate to local communities would have been welcome. What is stated now (all district hospitals are to be so upgraded), read in conjunction with repeated announcements and efforts to outsource district hospitals to corporate agencies, gives rise to fears that even this proposal, may be a justification for providing private medical colleges an access to the clinical exposure that the public hospitals provide.

The answers to any of the three challenges that a healthcare education policy faces, are not easy- but they are available, and across the world many nations have learnt to address them. Even for the most difficult challenge of the three- providing healthcare professionals with empathy and ethics, there are many innovative efforts to learn from. Even within the nation there are many good examples that the authors could have learnt from. Institutions like CMC Vellore have for over a century been identifying and training students from very remote and under-privileged communities and returning them successfully as sensitized caring individuals to serve these communities for a number of years, while maintaining standards of excellence far above the average. Far from learning from them, NEET has so comprehensively undermined these policies that CMC Vellore has had to petition the Supreme Court to try and safeguard their mission- as yet unsuccessfully. If select universities and regions did have the powers and flexibility and there was a suitable policy framework, which ensured that such flexibility was only exercised in favour of healthcare needs of the population and not for private profits, much could be improved.

But as it stands the policy has not seriously engaged with these questions. It is contradictory to its own stated objectives of a liberal education, fails to address concerns of equity in access to healthcare or access to healthcare education and paves the way for an unhealthy commercialization of education in this domain. There is a need for a re-think with more broad-based consultations, taking care to exclude conflicts of interests in the process of decision-making.

(Note: Both of the above articles have been published elsewhere. The latter on medical education policy is published in Frontline. This is with few edits to make it more relevant for this audience).

Tasks before Peoples Movements (these need to be deliberated upon and evolved in a national meet):

1. That there is a substantial increase in public financing of healthcare education, and complete abolition of capitation fees and management quotas.

2. That 100 % of seats are under price control- and in the event that this is unviable for private sector to manage these institutions, these should be taken over by the government.

3. That at least 50% of seats are free or nominally charged- so that all sections of society can access such education, and no student is denied access to education because of inability to pay for it.

4. That further seats in healthcare education be prioritized for districts with inadequate human resources- with matching policies to ensure local candidates and candidates willing to serve in these areas get preferential access to this education.

5. To demand that functions of regulation of quality in healthcare education be a state subject. The national accreditation and rating process would be voluntary and independent of permission and licensing. The National board can review the functioning of the state boards for quality in healthcare education, and where there are defects give directions to improve their functioning- but the actual assessment and action would be the responsibility of the state board. (if state board remains deficient, there has to legal remedies that the national board can resort to ??)

6. That quality of care in healthcare education be the function of state boards which have representation from healthcare professionals, educationists, health rights groups and administrators- and that these boards function in a transparent manner. The quality indicators of each institution need to be publicly displayed and based on processes established.

7. The selection processes should be fair and transparent- and may therefore opt for a common examination. The entrance examinations are best state specific with a central examination for only 15 to 30% of the seats. States could consider selections based on school board results converting school leaving scores into percentiles. Different forms of affirmative action to ensure under-serviced areas get the human resources they need should be encouraged.

8. The exit from healthcare educational institution should be by an examination conducted by the state university, and licensing should also depend on it. These examinations should be reviewed for quality, and these details be known publicly

9. Recruitment for government jobs- central and state- could use a common examination, and other employers could also use the scores on this examination for recruitment also.

10. The content of the healthcare education should include a strong foundation on ethics, gender sensitivity, constitutional obligations and equity- and should aim to build graduates who have compassion. This is not just a stated intention but should have clear processes and measures.

11. The content of healthcare education should also be appropriate to what is required of that category of professional in a given context. Setting of educational standards should reflect this. This may require the creation of new professional entities and courses.

12. There is a need for much better and much more extensive faculty development programs at all levels and for all healthcare education.

13. There has to be a rapid increase in the number of human resources employed by public health services, across the districts and states. This is essential to absorb the graduates from the healthcare education and to address problems of inequity in access to healthcare. Expecting graduates to find their own way in private markets for healthcare will merely lead to overcrowding and unhealthy competition in areas already having excess- while leaving large parts of India without essential healthcare services.

14. For regulation in professional ethics, state boards must be constituted for each profession, in each state. These boards should have leadership from within the profession, but there must be significant and empowered representation of other sections of society, so that it is not limited by professional solidarity, and can reflect larger societal objectives and concerns, while remaining fair and transparent. The national board can review the adequacy of the state boards and make directions to improve its functioning, but the actual implementation would be by the state board.