Draft Report of the High Level Group on Services Sector

5.3 Responding to Challenges

5.3.1 Regulation of clinical establishments and improving the quality of healthcare institutions
The High Level Group is of the view that it is imperative for the health and safety of the population to enforce minimum standards on clinical establishments in both the private and public sectors by laying down minimum standards and enforcing them rigorously. The Clinical Establishments (Registration and Regulation) Bill, 2007 having been introduced in the Parliament it would important to ensure that it becomes law at the earliest and that it enters into force for all the States and its applicability does not remain limited to four States and Union Territories. The next step would be for the proposed National Committee to set appropriate standards for all categories of clinical establishments.
Implementation of the minimum standards will only be the initial step for improving the quality of healthcare institutions in the country. The next step for improving their quality should be for all stakeholders to advocate that these institutions take advantage of the accreditation system already established in the country. It would be important for the Central and State Governments to take steps to enable the clinical establishments in the public sector also to avail of the accreditation system.
5.3.2Expanding Health Insurance
In the Central Government a health insurance scheme for the BPL categories is already taking shape following the recommendations of the National Commission for Enterprises in the Unorganised Sector (NCEUS). It is proposed to cover the entire BPL population of 30 crore (5 crore families) in five years time. It has been estimated that the premium per family would come to Rs 750, of which 75 per cent would be paid by the Central Government, the remaining 25 per cent coming from the State Government. The cost of the smart card will be borne by the Central Government and the beneficiaries would need to pay only Rs 30 per annum as registration/renewal fee. While the State Governments will determine the benefits that the beneficiaries would be entitled, the proposal is that hospitalization expenses will take care of most common illnesses, all pre-existing diseases will be covered, and transportation costs within an overall limit of Rs 1000 will be provided. The selection of the health insurance provider will be done by the state/implementing agency through a tendering process.
The High Level Group recommend that the Health Insurance Programme for BPL categories be implemented at the earliest.

5.3.3 Medical Education

There is a shortage of about 600,000 doctors, 1 million nurses, about 200,000 dental surgeons and large numbers of paramedical staff. Against this the annual turnover of medical colleges is about 30,000 of Dental Colleges about 20,000 and of Nursing Colleges (BSc Nurses) about 45,000 and of Nursing Schools (General Nursing Midwives and Auxiliary Nurse Midwives) about 60,000. The number of postgraduate degrees/diplomas being awarded annually in the country is only 3181/1316. The turnout of personnel with postgraduate is very low considering the number of teaching staff needed in the country as well as the requirement for filling up the openings now available in the country for Research & Development including Biotechnology. Additional demand has been created by the requirement of healthcare personnel from India in foreign countries, particularly in the US and the UK, and also the increasing opportunities in the country for medical value travel (medical tourism).
In light of the above the XI Plan envisages completing setting up of 6 AIIMS like institutions and upgrading 13 existing medical institutes. In the XI Plan it is envisaged that 60 new medical colleges and 225 new nursing colleges would be established in the PPP mode besides taking action for upgrading of nursing schools into colleges, strengthening of existing nursing colleges and up gradation and strengthening of existing government medical colleges.
The overriding requirement in the country is for increasing the supply of human resources at all levels, from specialists to paramedical personnel and to improve their quality. The Group is of the view that the only way to accomplish this is for the medical education sector to be opened up completely for private sector participation and companies to be allowed to establish medical and dental colleges just as they have been allowed to open nursing colleges. Other entry barriers such as the requirement of land and built up space need also to be lowered to realistic levels in order to facilitate the opening up of new colleges. Government’s role should be limited to opening a few high quality institutions dedicated to research. Having regard to the magnitude of the investment requirement for healthcare education and the paucity of resources with Government there is no alternative to allowing greater involvement of the private sector in health education.
In order to improve the quality of education in Government medical colleges it is necessary to give incentive to the teaching faculty. Wherever possible they should be allowed to undertake private practice and in other cases granted handsome non-practicing allowance. The private sector colleges will need to be regulated for their quality but no regulation is needed either for the fees charged by them from students or the emoluments paid by them to the teachers. As a measure of social equity they may be mandated to grant full or half scholarships for a proportion of the seats for meritorious students who do not have the means to pay the fees.
Ample supply of qualified personnel at all levels will not only improve the competitiveness of the private segment of the Indian healthcare sector but will also help to improve the efficiency of public health care institutions, which are at present handicapped mainly by personnel shortages.
The establishment of the regulatory Paramedical Council is crucial for expansion of training facilities and for improvement of the training programme in respect of paramedical personnel and the High Level Group expressed the hope that the law will be enacted shortly. The proposed Institute of Paramedical Sciences also needs to be set up urgently for enabling the implementation of a concerted programme for training of paramedical personnel in different fields. In addition Government should encourage private players, including large hospitals and hospital chains, to undertake training programmes under the regulatory control of the Paramedics Council.

A development council for taking wider initiatives for the training of paramedical personnel, such as the one proposed by the Group in Chapter I could also be considered.

Measures to improve the quality of education in the country will take time to fructify. As mentioned earlier in Section 5.6 the shortage of quality personnel has been exacerbated by the fact that the Medical Council of India does not recognize the undergraduate and post-graduate qualifications of institutions in countries that do not grant recognition to qualifications secured in India. As a result the hospitals and other clinical establishments cannot draw upon the pool of NRI medical professionals, who may be willing to work in India. The High Level Group is of the view that the qualifications of doctors and radiologists who have been trained in the UK or other foreign countries should be recognized by the Indian Medical Council on an exceptional basis in order to increase the pool of quality medical personnel available to the Indian service providers and increase their competitiveness in providing service for medical value travel, telemedicine as well as clinical research.
5.3.4 Boosting Clinical Research

The High Level Group considers the shortage of trained personnel to be the biggest challenge for improving the country’s competitiveness in the field of clinical research. The requirement is diversified and of substantial numbers. In line with the ideas outlined in Chapter I the Group recommends the establishment of a Clinical and Medical Research Council with the participation of the private sector for formulating, promoting and running training programmes for the area.

The Drugs Controllers office needs to be substantially strengthened and manned with personnel (including guest personnel from abroad) who are equipped with knowledge of the latest advances in medical research. A capacity building programme has to be undertaken and drugs testing facilities in terms of infrastructure and equipment augmented. A world class testing laboratory should be set up in the country in the PPP mode, where the Central Government gives assistance for construction of building and purchase of equipment but the management is undertaken by the private sector.

Arrangement needs to be made for accreditation of CROs for the purpose of certifying their adherence to Guidelines for Good Clinical Practices.

Chapter 6

Financial Services¹³