National Council for Human Resources in Health (NCHRH)
To overcome the acute shortage and uneven distribution of human resources in public health delivery system, the Ministry of Health & Family Welfare aims at overhauling the current regulatory framework. Toward this end, it is proposed to set up a National Council for Human Resources in Health as an overarching regulatory body to achieve the objective of enhancing the supply of skilled personnel in the health sector.
The general public is invited to go through the report of the Task Force and the draft bill and sent their comments / observations on the suggested provisions by the 15th October, 2009.
To reform the current regulatory framework and enhance the supply of skilled personnel in the health sector, the Government of India has proposed to set up a National Council for Human Resources in Health (NCHRH) as an overarching regulatory body. This follows the address made by the Honorable President of India, Shrimati Pratibha Devisingh Patil, to the Parliament on 4th June 2009 which mentioned setting up of such a National Council. Accordingly, a task force for setting up the National Council for Human Resources in Health was constituted on 22nd June’09 under the chairmanship of Shri Naresh Dayal, Union Health Secretary and eleven other members.
Membership of the Task Force:
The terms of reference of the Task Force
The Task Force was called to deliberate upon the structure and function of the proposed National Council on Human Resources in Health and to prepare a draft bill for setting up the said National Council. It met on four occasions, from 26th June, 2009 to 31st July, 2009 to develop recommendations which are contained in this report. Following members were coopted as mentioned below:-
Taking account of the present regulatory scenario of medical and health education in India, this report highlights the need for an overarching regulatory body and suggests the possible alternative in the proposed National Council. This Report is compiled in two parts with Part-I outlining the conceptual framework while in Part-II the Draft Bill for the constitution of the proposed National Council is annexed.
The need for the National Council for Human Resources in Health
The health sector in India faces critical challenges on several fronts despite significant achievements since Independence. While the country has made substantial strides in economic growth, its performance in health has been less impressive. An important reason for this is the inability of the health system to provide health care for all. Despite an extensive network of government funded clinics and hospitals providing low cost care, curative health services in India are largely provided by the private sector, tend to be concentrated in urban areas, serve those who are socio-economically better-off and place a substantial burden of out-of-pocket payments on patients. While India is one of the fastest growing economies in the world today, it is also one of the weakest performers in health. The importance of reforming the health sector has never been as critical as it is today.
Many of the issues facing India’s health sector today can be traced to distortions in the area of human resources in health. India faces a shortage of qualified health workers. Analysis based on the 2001 Census indicates that the estimated density of all health workers (qualified and unqualified) in India is about 20% less than the WHO norm of 2.5 workers (doctors, nurses and midwifes) per 1000 population, meaning that there are substantial shortage of qualified health workers in the country. The large geographic variations in the health workforce, across states and rural and urban areas are important challenges in reforming India’s health workforce policies. The disparity between urban and rural areas is particularly significant, as the urban areas account for less than a third of India’s total population but are home to a majority of health workers. Similarly, the concentration of health workers in the private sector is also a cause of concern, mainly due to the large number of vacancies facing the public sector and the higher cost of treatment involved in the private sector.
There are important distortions in the production of health workers in India. While there has been an increase in medical colleges in the last decade, it has mostly been due to an increase in private medical colleges in the southern states. Overall, the production capacity of doctors (and nurses) is much higher in states with better health indicators and this reflects the distorted distribution of the country’s production capacity of health workers. Private medical colleges also place a heavy burden of fees on students and their admission procedures are not transparent. The curricula of medical schools, both public and private, are not designed for producing ‘social physicians’ as envisioned in the Bhore (1946) and other Committees. Rather, the training they provide is better suited to the problems of urban India and for employment in corporate hospitals.
Nurses are another important cadre which has been ignored in our doctor-centric system as has been the tremendous potential they offer in providing health services in underserved areas. Nurses continue to have a low position in the health workforce hierarchy, while in other countries nurse-practitioners have elevated the practice and stature of nursing. Nursing education is also in a state of crisis with many nursing institutes being under-staffed and private institutes providing poorly trained nurses. The adverse nurse-doctor ratio of 0.8 remains a matter for serious concern. Nurses can deliver many of the basic clinical care and public health services, particularly at the community level, at a lower cost than trained physicians.
Professional councils such as the Medial Council of India, the Indian Nursing Council, and the Pharmacy Council have been set up by statutes of Parliament to regulate the practice of their respective professions, including education. However, many of these councils, besides being far too unwieldy have attracted criticism of their functioning, from health professionals’, health administrators and media. They have also drawn judicial censure on several occasions. Further, the existence of these different regulatory bodies, each responsible for important cadres of health workers have failed to provide a synergistic approach to addressing the human resources needs of the country. There is an urgent need for innovation in health related education which encourages cross connectivity across disciplines and categories of health workers. Any effort to make piecemeal changes in the existing Statutes is not likely to bring any substantial reform in the field of health education and services. The Indian health system stands to benefit tremendously from the generation of new cadres and competencies that can actively meet the health needs of the country. The broad vision of human resources in terms of the quantity, composition and quality required for enabling the country’s health system provide health care for all, is hidden from the perspective of these individual regulatory bodies. This makes the need for an overarching regulatory body critical for addressing the human resource issues facing the country.
The need for such an overarching body must also be viewed in the context of the proposed All India Council for Higher Education, recommended as a regulatory body for all tertiary education in India. While it is essential that institutes imparting health education maintain a close relationship with Universities imparting education in other disciplines, the need for developing and strengthening education in the field of health is of paramount importance to meet the health needs of the country, and thus needs singular focus and an overarching regulatory mechanism of its own.
Structure and functions of the National Council for Human Resources in Health
The National Council for Human Resources in Health (NCHRH) will be an overarching body, responsible for setting the mandate, coordinating and determining standards for health and medical education, and providing an overall framework for the regulation of human resources in health in the country. The proposed Council shall be constituted to amalgamate and subsume within itself the existing medical/health oriented councils viz. the Medical Council of India, the Indian Nursing Council, the Dental Council of India, the Rehabilitation Council of India and the Pharmacy Council of India.
Although functioning under the broad ambit of governmental policy on medical and health education of the Government of India, the Council will be constituted as an autonomous body, independent of Government controls with adequate powers, including quasi-judicial, to carry out the responsibilities it is charged with.
It will be the task of Council to prescribe the standards of health & medical education, and regularly redefine the nature and content of educational programmes required to meet the national needs for human resources in health. This overarching council will have within itself departments, each responsible to administer one specified cadre of health professionals. These will include Medicine, Nursing, Dentistry, Pharmacy and Rehabilitation along with Physiotherapy. In addition, it will also have departments of Public Health along with Hospital Management and Department of Allied Health Sciences which would include paramedics, lab technicians, optometrists, radiologists and the like. These Departments under the Council will act as the principal implementing agencies, responsible execution and monitoring of the standards, so established by the Council, within their respective streams.
It will also be the task of the Council to ensure, where necessary through its committees, effective use of linkages in the entire health system, act as the controlling and coordinating agency that ensures accountability in the system and to facilitate interconnectivity among and between disciplines while creating robust career tracks to meet the needs of a diverse and growing health system in the country. For example, when medical doctors have to teach nurses to become nurse practitioners or nurse anaesthesiologists, the specialised committee will provide guidance in meeting such demands.
Structure of the NCHRH:
The Task Force was of the opinion that the existing jumbo size councils comprising of nominated and elected members has not performed as expected and failed to meet the need of health professionals in the country. Therefore, it was proposed to establish a compact Council of professionals with only five members including the Chairman who are selected and appointed by the Central Government through fair and credible process. The Council, in its function, shall be assisted by a full-time secretariat headed by a Secretary General and the seven departments administering specific cadres of health professionals. Following figure-1 gives a diagrammatic structure of the Council.
Figure 1: Structure of the National Council for Human Resources in Health
* Allied Health Sciences would include paramedics, lab technicians, optometrists, radiologists and the like.
Composition of the Council:
The Central Government through a statute of the parliament shall constitute a body, comprising of five members including a full-time Chairperson, to be known as the National Commission for Human Resources in Health to exercise the powers and to perform the functions outlined in that Act.
Qualifications for the Members:
The Members of the Council should be Indian citizens of eminent ability, integrity, social commitment and professional standing with adequate knowledge and experience, at least of 10 years, in dealing with medical or health education, regulation of university level professional education or leadership of non-medical academic institutions imparting education in disciplines such as law, management or public administration.
Disqualification for appointment:
A person shall be disqualified for appointment as member of the Council if he/she is convicted of an offence involving moral turpitude, or is undischarged insolvent, or of unsound mind, or in service of Government or have such conflict of interest which is likely to affect prejudicially his /her functions as a member of the Council..
There shall be a Secretary-General, for a fixed term of 3 years, who shall be the Chief Executive Officer of the Council and in this capacity, shall head the Secretariat of the Council. He/she shall discharge such functions of the Council as may be assigned to him by the Council or the Chairperson and shall report to the Council through the Chairperson on such performance of his/her duties.
Appointment of Chairperson and Members:
The appointment of Chairperson and Members of the Council shall be made by the Central Government through Appointments Committee of the Cabinet on the recommendation of a Selection Committee consisting of the Cabinet Secretary, Principal Secretary to PM, Union Secretary Health and Family Welfare technical experts drawn from the Search Committee which would have provided a short list (on the ratio of 1:3) of suitable candidates to the Selection Committee.
Figure 2: Procedure for the selection of Chairman and Members
Appointments Committee of the Cabinet
Recommends 8 Names
Removal of Chairperson or Member:
The Central government may by order remove from office the Chairperson or any Member if the Chairperson or the Member, as the case may be, is adjudged an insolvent, or convicted of an offence involving moral turpitude, or engages in another paid employment outside the duties of his/her office, unfit by reasons of unsoundness of mind or body or have conflict of interest which is likely to affect prejudicially his/her functions as the Chairperson or a member.
Term of office:
The Chairperson and Members shall hold office for 3 years and not beyond 70 years of age, whichever is earlier and such term may, on a recommendation made by the Selection Committee, be extended to another 3 years.
No act or proceeding of the Authority shall be invalid merely by reason of any vacancy or defect or irregularity in constitution, appointment or the procedure of the Council not affective the merits of the case. If, for reason other than temporary absence, any vacancy occurs in the Council, the Appointments Committee of the Cabinet shall appoint another person from the panel of three reserve names recommended by the Selection Committee.
Functions of the Council:
The main purpose of the Council will be the promotion and coordination of medical and health education in India, to which end it shall perform, inter alia the following functions:
1. Academic functions:
3. Functions related to recognition of foreign degrees/qualifications:
National Level Exit Exam:
Though, all central and state universities shall conduct their own examinations and award degrees thereon, the National Council shall conduct National Level Exit Examinations to standardise post graduate and undergraduate medical and allied health courses. The National Board of Examinations (NBE) shall be archived with the coming into existence of the National Council.
Figure 3: National Exit Examination for health professionals (Post Graduation)
For the purposes of ensuring fair competition among medical and health institutions and to maintain quality, the Council shall empanel competent and independent bodies to perform the functions of assessment and accreditation in conformity with the norms that may be prescribed by the Council. Such process must be evaluated every two years for compliance and due diligence by the empanelled bodies and their empanelment reviewed on such evaluation.
Any empanelment, assessment, accreditation, review and the procedure and processes related thereto shall be considered public document and should be available, electronically or otherwise, for public access
Constitution of Committees:
Committees, which may be standing or adhoc in nature, may be constituted by the Council to fulfil specific functions as deemed necessary by the Council.
State/Regional Administrative Offices:
There may be established State or Regional Level Administrative Offices of the National Council, which shall act as the information, coordination and liaison office of the Council in such State or the Region as the case may be.
The State Registrations and Ethics Board:
The Task Force is of the opinion that with the repeal of the central legislations regulating the medical and allied health fields their state level councils also need restricting and the linkage between the National Council and the State Level Bodies needs to be outlined. In this regard there may be constituted a Registration and Ethics Board for each Department of health sciences in every State, which shall replace the existing State Councils (constituted under the statute of respective state legislature).
Each of such Board shall maintain, in the manner prescribed by the National Council, a state live electronic registers of the professional, which shall be linked to the National Register. The State Board shall be responsible to take cognizance and inquire into any professional misconduct and initiate appropriate disciplinary action against such misconduct in accordance with the guidelines and procedures laid by the National Council.
The State Registrations and Ethics Board shall comprise of:
The President, Vice-President and the Members, except for the one member to be nominated by the State Government, shall be elected from amongst the registered members of that Department in that state.
An appeal from the order of the State Registration and Ethics Board shall lie to the National Council, while any person aggrieved by an order of the National Council shall prefer an appeal only to a High Court and no other court shall entertain any suit, application or other proceeding in respect of any order made under the proposed Act.
Meetings of the Council:
There shall be a meeting of the Council in every quarter of the year and at least 50% + 1 members of the Council should be present to form a quorum for such meeting. All acts of the Council should be decided by a majority of the members present and voting.
Information to be furnished by the Council and publication thereof:
The Council shall furnish an annual report of its activities, copies of its minutes and abstracts of its accounts and submit it to the Central Government which the Central Government shall cause to lay for scrutiny before each house of the Parliament.
The Central Government shall be authorised to make rules while the Council may make the regulations, provided any regulation, except relating to academic functions of the Council should be approved by the Central Government to take effect.
Power of Central Government to give directions:
The Central Government shall have the power to give direction to the Council on questions of policy relating to national purposes which shall be binding on the Council.
The Task Force recommends for a periodic external review (every 5 years) of the functioning of this Council by an independent committee appointed by the Government of India.
Repeal and Saving:
With the coming into force of the proposed enactment the existing central legislations and the state legislations, wherever required, should be repealed. The central legislations that will have to be repealed include, The Indian Medical Council Act, 1956; The Pharmacy Act, 1948; The Dentists Act, 1948; The Indian Nursing Council Act, 1947 and The Rehabilitation Council of India Act in 1992. Notwithstanding such repeal, anything done or any action taken under such legislations should be deemed to have been done or taken under the corresponding provisions of the proposed Act.