Who Will Inspect the Inspector?

The inspection and approval of medical colleges in India is a shady business mired in corruption. But change is on the way.

There are incessant disputes which reach this Court about what actually transpired at inspections of various medical colleges by the Medical Council of India (MCI). The parties contest virtually every fact that is recorded in an inspection.

These opening lines in the Supreme Court order, pronounced by Justices SA Bobde and L Nageswara Rao, underlines the murky story of inspection of medical schools, and the sorry state of affairs of medical education in India. A batch of petitions were filed in the Supreme Court from private medical colleges in Kerala, who had been denied permission to admit students for academic year 2017-18.

The Supreme Court then went on to agree with the suggestion of Kapil Sibal, representing the medical colleges, to establish a “computer-network-based technological solution which might include artificial intelligence” to address the high litigation volume in this matter. The apex court then requested Nandan Nilekani to make adequate consultation, including with the IT industry, and provide concrete suggestions to the Court at the earliest.

This opens a window of opportunity to bring change in the beleaguered medical education regulation by ushering in transparency, timeliness and accountability by the use of technology.

The Murky World of MCI & Inspection

The Medical Council of India, now superseded by a seven-member board, is the regulator of medical education in India. Under Section 10A, read with Section 33 of the Indian Medical Council Act, the MCI, with previous sanction of the central government, can permit opening of a new medical college for a period of one year, with the permission renewed every year if the college meets certain annual targets. This annual inspection continues till the first batch of students pass, which amounts to five years of annual inspections. Thereafter the MCI and the Central Government, who have been vested with monitoring powers, can conduct inspections as and when required.

Medical education is highly regulated in India. Litigation arises because of both the regulator (which the Supreme Court famously dubbed as a ‘den of corruption’) and the provider is the same. This allows many medical colleges, offering substandard facilities in terms of human resource and infrastructure, to indulge in corrupt practices. The medical colleges usually complain of wrong noting of deficiencies and malafide intent of MCI inspectors — claims that have been upheld by courts on various instances. The colleges also complain that the rectification made after adverse reports are not heeded by the MCI. Aggrieved colleges usually approach the apex Court under Article 32 of Constitution of India, and in cases where High Courts order for re-inspection, the MCI approaches the Supreme Court.

In May this year, the CBI registered cases under Prevention of Corruption Act against MCI officials who were habitually taking bribes from medical colleges to get approvals. A medical college chairman was arrested in September 2017 for bribing MCI officials. The CBI earlier in August 2017 unearthed nexus between Ministry of Health and Family Welfare officials and private medical college management who sought favourable orders from the government. The situation is akin to the devil and the deep blue sea, represented by the MCI and the substandard medical colleges respectively.

In the past, when the Supreme Court appointed an Oversight Committee (OC) to improve medical education and review decisions of MCI, the OC accused MCI of violating inspection guidelines. Justice R M Lodha, who headed the OC, accused the MCI of not including assessors from the list that it provided. An ugly spat occurred in 2016 between OC and MCI when 109 new medical colleges sought approval from MCI and only 17 were permitted, while when the rest approached OC, 34 were permitted subject to pass fresh inspection.

The Court Resort

The Supreme Court in Medical Council of India vs Vedantaa Institute of Academic Excellence Pvt. Ltd. noted that in case of disputes regarding inspection, courts should interfere only when there are jurisdictional reasons like malafides of inspection team, ex facie viciousness in inspection, jurisdictional error by MCI, etc. And the apex court in many rulings has tried addressing issues pertaining to inspections.

One such crucial issue that the SC has heard is that of time schedule. Delay in granting permission or the denial of it wreaks havoc for medical seat aspirants, the colleges themselves and others. The Supreme Court has earlier taken note of this, and in Priya Gupta vs State of Chhatisgarh and Othersstated that neither the Central Government nor the MCI shall issue recognition or approval after 15 July each year. In another landmark case of Madhu Singh and Mridul Dhar earlier, the SC has fixed the deadline for MBBS admissions in the country as 30 September of the academic year.

In hearing the Royal Medical Trust and Another vs Union of India and Another, Justice UU Lalit emphasized that the MCI and the central government have to show ‘due diligence’ from the day applications are received to avoid confusion regarding admissions which affects all.

Earlier this year the union health ministry acting on recommendation of MCI denied permission to 82 medical colleges in the country to accept students for 2018-19 while rejecting 68 applications for setting up new medical colleges in June this year creating panic among MBBS aspirants and jeopardizing nearly 15,000 seats. For a country with a poor doctor-patient ratio (of as low as 1:11,000 as per the last NHM report) these decisions based on the inspection reports, most of which are challenged and all of which are kept shrouded in secrecy, are detrimental.

Technology to the rescue?

A cursory look at the 143 pages of “Minimum Standard Requirements For The Medical College, For 100 Admissions Annually Regulations, 1999” will show how detailed the requirements have been from human resource to material resources. The only catch is that it is too detailed. The dimension of a room for a professor, and for a junior resident is specified. The make and details of tables that are to be used in an anatomy dissection hall is specified. It is these centimetres and millimetres that are often considered in filing compliance or lack thereof.

Bringing technology to address inspection issues has to be preceded by a policy and cultural shift in the regulatory authority vis-a-vis inspection and approval.

As the former Vice-Chairman of NITI Aayog, Arvind Panagariya had noted, it is this focus on adherence to strict infrastructure and personnel norms that has led to widespread corruption. The National Medical Commission (NMC) Bill plans to replace inspections by an accreditation system. The Bill also proposes increase of seats without approval once standards are met and similar provision for starting PG courses. This is a welcome step and with the Bill likely to be tabled soon, this change on the anvil has the potential to address many  inspection issues related to corruption.

If one is to cite an example of how technology, backed by pragmatic policies stemming from a radical change in thought, made an otherwise harassing procedure easy, it would be that of the passport revolution in India in 2008. Thinking on similar lines could help save medical education in the country.

The first step in developing a technological framework would be to identify what aspects of inspection can be done away with. For example, a professor in a teaching department regardless of sitting in a 12 sq meter room or 16 sq meter room would discharge the same function. This exercise aligning with provisions in NMC Bill will be helpful in bringing much needed clarity to the process.

Secondly, the team should identify what are the priority areas that determine quality of medical education and explore how technology can help in recording those domains. For example, if faculty number, faculty presence, patient load and equipments are of high importance, then use of biometrics (already in place in most colleges but not in functional state), RFID/bar code for instruments, equipments, patient entry data verification could be explored. Colleges should self-declare, subjected to scrutiny, other low priority information on to the database.

A third task would be to link all these to a central or state level database which is accessible to all.  The Central Information Commission in July this year while responding to an application to review the inspection report of Gandhi Medical College, Bhopal, directed the MCI to place in public domain all inspection reports within six weeks of their filing. Then Chief Information Commissioner Yashovardhan Azad’s question to MCI official seeking reasons for keeping inspection documents classified under Section 8 was unanswered. Transparency would go a long way in helping students, their parents and the general public.

Fourthly, as the SC has mentioned, the team can consider how Artificial Intelligence (AI) can be put to use. For example, there is a requirement of 470 beds in a teaching hospital looking for an admission of 100 MBBS students. Usually colleges bring in patients during inspections to show the numbers. Use of AI could track patient load throughout the year, observing these spikes and patterns, taking into account the regular cycle of patient load, and help make informed decisions. If infrastructural facilities are tagged and linked to the database, real-time analysis can help identify if they were just rented for inspection or the college actually possesses them.

To bring in a technological framework to do all this will be a capital-intensive process. However, given the high positive externalities of quality medical education in the country, this investment is warranted. It would also save the time-consuming and costly process of the vast amount of litigation currently associated with this process of inspection.

The Way Forward

There is no doubt about the fact that the inspection and approval of medical colleges in India is a shady business mired in corruption. This has been the practice for decades. While the blame rests on the shoulder of the regulator, the nefarious network of private medical colleges have fanned such nepotism. Some changes are on the anvil with the NMC set to replace the MCI. However, unless the culture, the bureaucrats, the officials and the policy of this organization do not change, it will have little impact.

In roping in technology to address this murky business of inspection and the humongous litigation it leads to, the Supreme Court has given all the stakeholders an opportunity to demand and expect greater transparency. Technological solutions have ushered change in many otherwise corrupt processes, and it can do so for medical education too.

About the author

Sambit Dash

Sambit Dash is a faculty in Melaka Manipal Medical College, Manipal Academy of Higher Education. He is an alumnus of Takshashila Institution. He comments mainly on topics related to education, healthcare, science, Malaysia and Odisha.