December 28, 2007

Get a Doctor in the Village, how!

The recent controversy regarding the village posting of doctors has
put the medical community on one side and the whole world on the
other side. I remember, 35 years ago, when I was selected for
medical college I went to one of my elderly aunts to seek her
blessing. She was not very happy about the issue, no, she was not
jealous, but she expressed her anxiety very eloquently. "You are
such a nice boy, but now you'll become a bad man". That, I think,
sums up the attitude of the society towards the doctors.

The problem possibly lies with the doctors. They work for money,
they do not bother about the society, they can kill female fetuses
for a few bucks more, and they can refuse treatment for want of
money; they are not up-to-date with knowledge, they do unnecessary
tests to get a share of the booty. Most of the complaints are
probably true. I have seen ultra-sonologists giving shamelessly
false report to assist another shameless gynecologist in going for
an unnecessary surgery, and I have seen many more un-parliamentary
linen that I should not wash in public. All are true and more.

My worry is about the ways the society is trying to go about solving
the problem. The society is trying to find a solution without
assistance from doctors. It was the same when the consumer
protection act came. Most of the sane doctors protested, some insane
ones also did. No one listened to us. I remember having told one
gathering of legal experts, that they were putting the patients from
the frying pan to fire; from doctors clutches to lawyers. I asked
them, why did they want consumer protection act for the medical
community, to improve services or getting compensation, or did they
want just to teach a lesson! I assured them none of these would be
possible. People refuse to learn from history. Has the road accident
compensation policy improved the quality of drivers? It has only
raised the insurance rates and probably helped the family of the
dead. If consumer protection act implementation for medical
community was intended for compensation, it was good, but if it was
meant to improve services, it was useless. People gave us funny
looks, thought we were `so bad'.

Now the great thinkers of the nation are again at it. They want
doctors to go to villages, and because the anti-social doctors do
not want to go to villages, they'll have to be forced. I am
surprised at the cerebral quality of the people who rake up such
ideas. Has any one tried to find out why doctors are not interested
in going to the villages! Is it only money! By the way, one of the
lowest paid employees in India is a junior doctor. As a junior
doctor I was paid a princely sum of Rs. 225/- PM, while the ward
boys were paid Rs 400/-. Their duty was 8 hrs, mine 24 hrs; they had
one weekly holiday, I had none. They had time for lunch; I did not.
I survived because the `sisters' were real sisters; I shared their
food. If the barber failed to turn up, I had to `prepare' the
patient for surgery; the ward boy would not even have a nightmare of
doing it. If the ward boy were absent I had to `ensure' that the
patient reached the OT on time, riding on the trolley, guess who
pushed it through the corridors of the hospital! But I tell you; I
enjoyed my stay as a house surgeon. I am still proud of what I did.
Because that was when I learned. That was what prepared me for the
future. That is where I learnt how to give a painless suture, how to
tackle a violent patient, how to tackle grief. I do not think a Lal
Bahadur Institute trained babu will ever understand that, they do
not have the training.
Look at the position of medical education today. MBBS is a five and
a half years course. Already the longest course in the country. But
an MBBS degree is truly nothing today. At one time an MBBS degree
was equivalent to an M Sc degree. One could become a lecturer after
MBBS, could do a Ph D, or D Sc after MBBS. But no more, now MBBS is
equivalent to B Sc. MD was a doctoral degree, Doctor of Medicine,
now a postgraduate degree, a three years postgraduate degree. A two
years postgraduate diploma is not equivalent to M Sc. Even the MCI
is trying its best to degrade the status of medical degrees.

I invite the society to understand the problem first. Force should
come as the last option, not the first. Today an MBBS degree holder
is a pariah in society, to be accepted by the people he has to have
a postgraduate qualification. `Only MBBS', or `simple MBBS', or
worse `plain MBBS' are terms we hear often, but do not understand
the agony of it all. MBBS entrance is one of the toughest in the
country, but let me introduce you to a tougher entrance, the PG
entrance. The number of seats for PG is one third of the total MBBS
seats, so in any case two thirds of the MBBS shall remain `plain and
simple'. This cutthroat competition has prompted the students to
treat MBBS degree as a qualifying benchmark for PG entrance tests.
They prepare for the test rather than trying to become doctors. This
one entrance test would make or break their career. It is better to
be a simple B Sc then to remain a simple MBBS. There are instances
where MBBS students are paying smaller hospitals to get internship
certificate without going to the hospital so that they can utilize
the time studying. What is the result? They do not become a `doctor'
after MBBS; they remain students. One third of them get into PG, two-
thirds fail. No, not because they are stupid, because the know-all
government has put a rationing in the number of seats for PG.
Imagine the fate of these students, they are plain MBBS, did not
spend time learning during internship, now they are out in the open,
no respect, no knowledge, official quacks. This is the most serious
wastage of trained manpower the country is facing today, all because
of our policy makers.

Who is responsible? There was one know-all TV talk show, which said
if you cannot become a doctor in five years, you could never be. So
cerebral! These are the people who control the society, God help us.
One does not become a `doctor' immediately after passing MBBS; it
takes at least 2-3 yrs of fulltime work under supervision to be able
to work independently. That was what house jobs were. Earlier house
jobs were compulsory before MD entrance. After 2 house jobs if one
did not get in to PG one could still practice. Now house job has no
PG entrance value. Practicing medicine without a House job does not
prepare a doctor well.

Is there a solution to the problems in villages? It is there, if our
great parliamentarians bother to listen to us. By the way I have a
few more proposals. I want to make it compulsory for the
parliamentarians to stay in a village for one year as MP and fulfill
all promises made during election campaign otherwise their
Membership would be cancelled. Make it compulsory for IIM graduates
to stay in a village for one year to work for betterment of rural
finances, before they get their degree. I want High Court judges to
stay in villages at least 2 months a year to help solve the pending
cases in the villages to be eligible for promotion to Supreme Court.
I want the IAS officer to be posted in a village for one year before
they are confirmed in their jobs.They can all stay in the excellent
accomodation provided in the villages for the doctors. Sounds funny?
Who started the jokes!

Here is what I suggest.

The entire medical course needs to be revamped. Instead of hundreds
of confusing degrees there should be one degree, MD. It should be a
nine years integrated course, equivalent in status to a Ph D. All
students, after four years, would get a provisional registration to
work as doctors under supervision. They would select their specialty
at this juncture, depending on the merit and other government
policies of the time. Even a surgeon would be MD. All the diploma
courses would be abolished. There would be specialties in family
practice, clinical medicine, hospital based internists, surgeons,
ophthalmologists, and all other specialties that we have today.

One year out of this course will be a village posting where they can
learn the problems of the villages and unlearn some hi-tech
solutions to simple problems. There would never be a shortfall of
doctors in villages, happy doctors and not frustrated ones. I do not
think there would even be a murmur of protest from anywhere. No
forcible "Cultural Revolutionary" tactics would be needed. The GPs
that we get would be trained ones, not untrained ones as we get now.

How does a patient differentiate between a physician MD and a
general practitioner MD. The same way they do now, between MDs in
Medicine, pharmacology, biochemistry and pathology. In any case,
government can recognize certain associations, memberships of which
can be made compulsory. (For example, MD, Member of Indian College
of Pharmacology, or MD Indian College of Surgeons.). This way every
doctor that comes out of the college would have some special skills,
and have worked independently for at the least 4 years before being
released to the society. There is no wastage of doctors as `simple
MBBS'.

The super-specialties should be limited to a few, the brightest
ones. There should be no further confusing degree like M Ch, DM. The
super-specialists would be offered fellowships of the college, e.g.
MD, Fellow of the Indian College of Cardiac Surgeons, equivalent to
postdoctoral degree, D Sc.

By the way this does not solve the problem of the bad guys in the
profession as mentioned in paragraph two of this article. I'll share
a bitter truth with you. The patients are as much responsible for
this situation as the doctors. The ratio of good doctors and bad
doctors is exactly the same as the ratio of good guys and bad guys
in the society, not more, not less. There is something very wrong in
the way patients select their doctors. Name and fame does not depend
on skill, knowledge and sincerity. Sound business tactics, sometimes
not so ethical, makes one doctor more popular than the other.

This article is aimed at sensible people who want a solution, not
revenge. The next doctor could be your son; the next patient could
be your son.

- Dr Ashok Sinha
ashokagt2@yahoo.com.
79 Tilla,Kunjavan, Agartala, Tripura.

Global medical tool makers throng India

Even as a lack of clarity in regulations is preventing Indian medical device manufacturers from making their presence felt in the $2 billion domestic medical equipment market, foreign players, mostly from the United States, are increasingly finding the country a preferred destination.

The tremendous growth projections have also prompted foreign medical equipment makers to float Indian subsidiaries -- 30 of them received import clearances in 2007 alone -- to move away from the earlier practice of indirect operations through authorised agents in India.

Boston Scientific, Abbott, Becton Dickinson, Guidant, Medtronic, B Braun, Johnson & Johnson, DePuy, Advanced Medical Optics and Stryker are among the leading firms, whose Indian subsidiaries received approvals to import medical devices during the year.

Corporate interest in the Indian healthcare segment and the introduction of the product patent regime in 2005 are known to be the prime movers behind India becoming a hot destination for medical device firms across the world.

A recent FICCI-Ernst & Young study had predicted 15-20 per cent growth for the Indian medical equipment market and estimated market size to be about $5 billion by 2012.

“With the kind of attention the government and the corporate world has given to India’s healthcare sector, the growing interest of foreign players in the medical equipment sector is quite expected. I would be surprised if companies are not coming to India,” says Anjan Bose, chairman, medical electronics forum, FICCI.

According to Bose, India has to join hands with the industry to decide on an appropriate monitoring mechanism to ensure the quality of medical devices reaching India.

Ram Sharma, managing director, Becton Dickinson India, and chairman, medical equipment committee, American Chamber of Commerce in India, also highlights the need for regulating the medical equipment sector.

“We strongly recommend that instead of re-inventing the wheel, India learn from the experiences of other countries that have brought in regulation in the medical technology sector. The focus should be on making the regulatory process transparent and geared towards patient safety. It is highly desirable that the government pools resources with the Global Harmonization Task Force to enable shared learning and benefit from their experiences in the field of medical devices regulation worldwide,” said Sharma.

Though the domestic industry shares the same view on the need for clarity in the regulations binding medical equipment, it complains that Indian regulators adopt double standards in giving marketing approvals for medical devices.

“Indian medical device makers are equally quality conscious. While the Central Drugs Standard Control Organisation allows import of medical devices on the basis of the quality certifications these products have received from foreign authorities, they insist upon unrealistic standards for the Indian industry,” Himanshu Baid, managing director, Poly Medicure, said.

Baid says that Indian drug regulators are applying manufacturing standards meant for pharmaceuticals on medical device facilities.

“Our products are exported to 65 countries including developed markets. Even though we have all certifications needed for exports, our regulators find that insufficient. There has to be some clarity on this before Indian players can sell their cost-effective devices in the domestic market,” Baid added.

Domestic players also allege that the absence of pricing norms is allowing bigger players to charge exorbitant prices for their imports.

Incidentally, the growing demand for medical devices and its cost have also found mention in a recent study carried out by the Delhi-based Society for Economic and Social Studies.

The NGO, which reviewed Indian patent applications for a collaborative project that involved the health ministry and WHO India office, found that a large number of patents have been granted in the area of medical devices during the last three years.

“Sixty four patents have been granted for medical devices in India from 2005 to March 2007. This has obvious public health implications as there is evidence that the cost of devices and diagnostics are starting to form a large proportion of treatment costs. It also points to the necessity of patent examiners being judicious while granting such patents, keeping in mind the three main criteria for granting a patent -- novelty, usefulness and application,” the study said.

December 23, 2007

Screening of new born baby to be made mandatory

Goa government is contemplating the possibility of making screening of new born babies mandatory in the state, which will help medicos to track down and diagnose any deformities in the initial stage itself.

"If we are able to do it, then Goa will be the first state in the country to have mandatory baby screening soon after the birth," state Health Minister Vishwajeet Rane said.

The state, with 14 lakh population, has a considerably good health services with low infant mortality rate.

"If we are able to trace deformities at initial stage, we can correct them rather than waiting for the child to grow," Rane said adding that Delhi government is working on a similar lines but Goa wants to be the first state to implement it.

Rane has also got the consent from the state Chief Minister Digamber Kamat who during his Liberation Day speech on December 19 made a special mention about the plan.

The state Health department, which has failed to make HIV testing mandatory following opposition from certain section, is pressing hard for this new concept.

To ensure that every parent get their child screened, the health minister said, "If they don't screen the baby within 48 hours, than they will not be given a birth certificate.

Rane said the mandatory screening is adopted in places like Philippines, Bangladesh, Singapore and Abu Dhabi, and will be implemented in Dubai from first of January.

The health minister also said that the government intend to set up medical city in the state, which will not only increase tourism but also give Goans access to world class medical facilities, Rane said.

December 18, 2007

Indo-Malaysian venture to train doctors

Considered as the first Indo-Malaysian joint venture by a private medical institution, the Bachelor’s of medicine and Bachelor of surgery programme offered by Melaka Manipal Medical College is becoming a favourite among Malaysians.

With 250 students currently enrolled in the programme, the institution is playing a major role in training Malaysian doctors. The college offers a twinning MBBS degree for medical undergraduates. Students undergo two and a half years of basic sciences and introductory clinical training in the Manipal campus in Karnataka and the remaining two and a half years of medical training is completed in the Melaka campus, Malaysia.

According to P Sripathi Rao, dean, Kasturba Medical College, Manipal, the five semesters of the course conducted in Manipal includes basic sciences and pre-clinical subjects with clinical training. “In Malaysia, students continue with their clinical training. In Manipal, each student is assigned a lecturer who act as a guardian,” he added.The medical college was created in 1997 following an agreement between the governments of Malaysia and India.

“The two governments signed an MoU to train Malaysians students in India. Malaysia has a long history of having many of its doctors being trained in India. And Manipal was chosen as the medical partner in India,” said Rao. “In February 2004, Melaka Manipal Medical College was included in the WHO directory of recognised medical colleges. Also, in the international medical education directory of the Educational Commission for Foreign Medical Graduates.

The degree offered by the Melaka Manipal Medical Colleges is also recognised by the Sri Lanka Medical Council,” said Vidya Pratap, director, PR.

Apollo Hospitals to invest Rs 600 cr in tier II cities

Apollo Hospitals has chartered out a massive Rs 600-crore expansion plan to make its presence felt in tier II cities.

Apollo Hospitals MD Preetha Reddy told ET, “We have finalised our decision to enter the tier II cities. Initially, we would come up with 10 hospitals across the nation.”

The company would come up with 150 to 200 bed capacity hospitals in tier II cities across the length and breath of the country and is under the process of identifying locations for the proposed hospitals. Ms Reddy said that the management would invest Rs 50-60 crore in each of its hospital.

Apollo had appointed a US-based consultant company specialised in healthcare projects for drafting the nitty-gritty of its entire plans. “In total, we would be investing Rs 600 crore for our 10 hospitals in the tier II cities,” said Ms Reddy. The funding would be a mix of equity and debt. However, the ratio is still being worked out.

Andhra Pradesh Doctors to get security cover

If you get violent with a doctor in Andhra Pradesh while he or she is on duty hen be prepared for three years of jail.

The Dr Rajasekhara Reddy government has issued an ordinance to ensure safety to doctors. The Ordinance says any act of violence on a doctor, nurse or paramedical staff while on duty in a government or private hospital, will lead to three years in jail.

After the government's decision, the doctors called off their strike and will join work from tomorrow morning.

''So far it was just three months of jail and was a bailable offence. Now if property is damaged or if a doctor is assaulted then he will straight go to jail and only the magistrate will have powers,'' said Mohd Shabbir Ali, Cabinet Minister, Andhra Pradesh.

Doctors in Andhra Pradesh have been protesting against three incidents of assault on them by relatives of patients.

The ordinance cleared by the cabinet says that any damage to property and equipment will also be construed as an offence.

To take care of complaints by patients or their relatives, a Grievance Redressal Authority will be set up in all government hospitals.

''We hope that it will be enforced and implemented. We should feel protected only then will our minds work freely and we can give better service,'' said Dr Janaki, Government Doctor.

Junior doctors or medical students however say they will continue their strike until Special Protection Force is posted to guard all government hospitals. Junior doctors work as an extended arm of the government doctors and mainly take care of out-patients

British NRI docs looking back at India

India is now experiencing a reverse brain-drain with its well resourced hospitals with state-of-the-art facilities wooing back a sizable number of NRI doctors, who worked with the National Health Service of Britain for years.

Quoting the director of one of India's leading private hospital chains, The Sunday Times reported that he was receiving five job applications a week from NHS doctors and that half his 3,000 consultants were from Britain.

"There's a feeling that India's time has come and there's a huge need for these people to come back," Anupam Sibal, director of the Apollo hospital in Delhi said.

Doctors say they are moving to India because of its economy, state of the art equipment, higher standards than the NHS and a better quality of life.

There has been a boom in private hospitals in India that resemble luxury hotels, with marble foyers and corridors mopped by an army of liveried cleaners.

One of those who have made the transition is Mahesh Kulkarni, an orthopaedic surgeon, who left Bristol Royal Infirmary after 10 years in Britain. He is now a consultant at the Aditya Birla Memorial Hospital in Pune.

"The hospitals are better than in Britain. They are spotless and clean compared with the old hospitals in the UK, some of which are more than 100 years old," he said.

Govt to recognise medical degrees of foreign nations

In a decision likely to benefit Indian doctors settled abroad wanting to return to their motherland, the government proposes to recognise the medical degrees of other countries, including the United States and United Kingdom.

Addressing an Indo-US health summit here, Health Minister Anbumani Ramadoss today said the government proposes to recognise the medical degrees given by countries like United States, United Kingdom, Australia, New Zealand and others.

"I want the support of the Medical Council of India (MCI) on this," he said.

"A lot of Indians who have gone there, studied there, want to come back. The government of India has proposed that we need to take a decision so that a lot of doctors who want to come back to India can do that," he said.

Asked on whether New Delhi should wait for these countries to recognise Indian degrees, he said, recognising their degrees first would be a step forward. "It is to our advantage. It is the first stage, eventually they would reciprocate," he added.

Ramadoss also emphasised the importance of changing the curriculum for emergency medicine in the courses being offered in India. "The concept of emergency medicine is not developed in India even though most of such specialists abroad are Indians," the Minister said.

Ramadoss added it was the curriculum at the undergraduate level which needed to be changed. "We need an international and more practical curriculum," he said.

December 15, 2007

US gives parity status to India's medical education

The United States has said India's recognition system for under-graduate medical courses is at par with theirs, an achievement that could facilitate mobility of doctors from here to US.

National Committee on Accreditation in the US, the apex body responsible for foreign accreditation, has granted parity to the recognition system in India for the courses.

"The MCI had sought parity status from the National Committee on Accreditation. It was granted last month, which means quality wise, the under-graduate courses in India are at par with the US," Dr Vedprakash Mishra, Vice-Chancellor, Datta Meghe Institute of Medical Sciences University, who was part of the MCI team to negotiate with the US agency, told reporters at the Indo-US Healthcare Summit here.

The parity has been granted for two years. "During this period, our recognition system will be monitored by them. Then India will get permanent parity status," he said.

December 14, 2007

Medical apex body to be set up on the lines of UGC

The Union Ministry of Health and Family Welfare has come up with a proposal to set up a Medical Grants Commission (MGC) on the lines of the University Grants Commission (UGC) to regulate all medical colleges in the country.

According to Ministry sources, there are about 262 medical colleges in the country at present and the number is growing constantly. "A need was felt for a Commission to support Government medical colleges in the country. The UGC has a mechanism for assisting the colleges but we do not have any such mechanism so far. We thus thought of an apex body on the lines of the UGC," said an official of the Ministry.

As per the plan, the MGC will regulate the growth of substandard medical and dental colleges, and will also help rationalize their fee structure. "The MGC will aim at putting an end to the malpractices associated with running private medical and dental colleges," added the official.

The official further added that for maintenance of a medical college, it needs huge funds which the state Government is unable to support.

In the recent times, there has been a significant rise in the numbers of private medical and dental colleges which are neither having appropriate infrastructure, nor providing quality teaching.

The guidelines for the setting up of MGC are being worked out. Though it will be primarily based on the UGC model, it will not be completely replicated.

The plan is at its initial stage and once finalized, it will be sent to the Parliament for its approval.

At present, the Medical Council of India (MCI) is the statutory body that evaluates the applications for new colleges and also regulates the functioning of colleges to some extent.

India, France to co-operate on basic medical research

India and France have joined hands to explore the possibilities of RNAi (RNA interference) in areas of basic medical research and biotechnology.

Inaugurating a three-day conference at the Centre for Cellular and Molecular Biology here on Wednesday, the scientific and programme officer French Embassy, Bruno Rouot, said that teams of scientists from India and France are jointly working in areas like Chemistry and Biology.

Eight Indo-France lab centres have already been set up and two research institutes are working in Pondicherry and Delhi. To further this programme and encourage scientists, scholarships and fellowships are also being awarded. There are seven scholarships for Indian students to the tune of 1300 Euros for six month duration, Rouot said.

He said joint research cells are working on water and ground water. He said that 250 projects were approved in 2006 as a part of the joint collaboration between India and France.

Participating in the meet, Chantal Vaury INSERM, Clermont Fd, France in Drosophila (fruit fly) said that in the area of basic research it is important to know how the cells work.

One project is already underway and the conference will work to establish connection between scientists from India and France. The ongoing project will analyse expression of genes with nuclei, she said.

Scientist are trying to understand the RNAi interference in positioning the regulation of expression. In medical research it is working in areas of fighting diseases like HIV, virus related diseases or how to cure a genetic programme that is going wrong. In areas of bio-technology, it informs how to silence a gene, she added.

December 12, 2007

Medical evidence more credible than eye witness account: Supreme Court

In an important judgement on medical jurisprudence, the Supreme Court had held that medical evidence will prevail over the eye-witness account if they were contradictory.

"The medical evidence will assume importance while appreciating the evidence led by the prosecution and will have priority over the ocular version and can be used to repel the testimony of the eye-witnesses," a bench comprising Justices P P Naolekar and Justice D K Jain said.

The Bench passed the order while setting aside a lower court's judgement which had sentenced four people to life imprisonment for killing a man in 28 years ago.

In the lower court it was alleged the accused had entered into the house of deceased around midnight and had beaten up his family members which according to prosecution led to death of one member.

All the eye-witnesses, while deposing before the trial court, had categorically stated the deceased was injured by the use of firearms.

But post mortem of the body showed that there were no indication of any firearm injury on the person and no pellets, bullets or any cartridge were found on the body.

Rejecting the eye-witness account, the apex court said, when medical evidence specifically rules out the injury claimed to have been inflicted as per the eye-witness version, then the court can draw adverse inference that the prosecution version is not trustworthy.

December 10, 2007

Govt thinking of single medical authority for PG Education

The government is considering setting up a unified authority for regulating post-graduate medical courses in the country, Health Minister Anbumani Ramadoss said on Friday.

“In India, we have two authorities to regulate post-graduate medical education; the Medical Council of India and the National Board of Examination,” the minister told Rajya Sabha in response to supplementaries during Question Hour.

The minister acknowledged that MCI-regulated post-graduate education has been recognised by many countries except in the neighbourhood. “But as far as National Board of Examination is concerned, there has been wider acceptance internationally because of the standards of education and its quality,” Ramadoss said.

The minister, however, emphasised the government would take a final decision on the recommendation for a unified authority only after consultations with the stakeholders concerned. He also declared the government was going in for a drastic change in the curriculum at both levels. “The curriculum we are following today is a little outdated. Hence, we are going in for a new curriculum change according to modern concepts, modern technology development,” he said.

The minister, who’d been pushing for a mandatory stint for young doctors in rural areas, also said the government was going to allow government hospitals at district headquarters to join hands with private players to start medical colleges. This is to bridge the divide between six states where two-thirds of India’s medical institutions are located and the rest of the country.

Of the 270 medical colleges in India, six states — Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, Gujarat and Maharashtra — account for 180 of them. The remaining 23 states share the rest.

“There is a huge lacuna in the states of Uttar Pradesh, Bihar, etc. Bihar has only eight medical colleges for a population of 110 million. Uttar Pradesh has 16 and Madhya Pradesh has eight. In the Northeast also, there has been a huge lacuna,” he explained.

December 06, 2007

Medicines may get cheaper

In a major blow to chemists charging hefty margins from consumers, the government has decided to limit trade margins on all medicines sold in the country. The move will take away companies’ freedom to decide trade margins for almost three-fourths of the market. Currently, trade margin cap is prescribed for only one-fourth of the Rs 35,000-core domestic pharmaceutical market.

The margin for this three-fourth of the market will be fixed at 10% of the maximum retail price (excluding excise duty and other applicable levies) for wholesalers and 20% for retailers, government sources said. Consequently, the retail prices of medicines may come down. A notification to this effect is likely in the next couple of weeks. The ministry is expected to amend the drug price control order of 1995 soon to introduce the caps.

Sources said margins for a smaller fraction of the market — brands sold by their chemical name, which account for less than about 5% of the market — will be fixed at 15% and 35% respectively.

Reigning in trade margins was a priority for chemicals and fertilisers minister Ram Vilas Paswan, who had earlier asked companies not to charge margins as high as 10-20 times the cost of production on many drugs.

The policy will be enforced by National Pharmaceutical Pricing Authority (NPPA). The chemicals and fertilisers ministry has already said it would be the price watchdog’s responsibility to monitor overcharging of trade margins.
There will, however, be some exemptions for the small scale companies as most of them rely on chemists unlike bigger companies that employ a vast army of salesmen to ‘educate’ doctors about their brands.

Small companies will be allowed to pay an extra fee to the chemist as a support to compete with larger firms. In terms of percentage, it is this segment where margins are the highest. Bringing margins from above 1,000% of production cost to 50% (wholesale and retail together) would benefit the consumer, and at the same time, the extra fee would still give them an edge over bigger rivals.

It is to be noted that for the three-fourth of the market where new margins are being notified, there is no check on the retail price. That is, companies are free to decide a price but have to restrict trade margins to a percentage of that. Earlier it was thought that increasing the retail price would enable companies to give a higher margin in rupee terms, while complying with the percentage ceiling.

However, with the National Pharmaceutical Pricing Authority strictly enforcing the cap on annual price increase — 10% since early this year — on all medicines outside government price control, a cap in percentage terms is considered not prone to abuse.

Medicines may get cheaper

In a major blow to chemists charging hefty margins from consumers, the government has decided to limit trade margins on all medicines sold in the country. The move will take away companies’ freedom to decide trade margins for almost three-fourths of the market. Currently, trade margin cap is prescribed for only one-fourth of the Rs 35,000-core domestic pharmaceutical market.

The margin for this three-fourth of the market will be fixed at 10% of the maximum retail price (excluding excise duty and other applicable levies) for wholesalers and 20% for retailers, government sources said. Consequently, the retail prices of medicines may come down. A notification to this effect is likely in the next couple of weeks. The ministry is expected to amend the drug price control order of 1995 soon to introduce the caps.

Sources said margins for a smaller fraction of the market — brands sold by their chemical name, which account for less than about 5% of the market — will be fixed at 15% and 35% respectively.


Reigning in trade margins was a priority for chemicals and fertilisers minister Ram Vilas Paswan, who had earlier asked companies not to charge margins as high as 10-20 times the cost of production on many drugs.

The policy will be enforced by National Pharmaceutical Pricing Authority (NPPA). The chemicals and fertilisers ministry has already said it would be the price watchdog’s responsibility to monitor overcharging of trade margins.
There will, however, be some exemptions for the small scale companies as most of them rely on chemists unlike bigger companies that employ a vast army of salesmen to ‘educate’ doctors about their brands.

Small companies will be allowed to pay an extra fee to the chemist as a support to compete with larger firms. In terms of percentage, it is this segment where margins are the highest. Bringing margins from above 1,000% of production cost to 50% (wholesale and retail together) would benefit the consumer, and at the same time, the extra fee would still give them an edge over bigger rivals.

It is to be noted that for the three-fourth of the market where new margins are being notified, there is no check on the retail price. That is, companies are free to decide a price but have to restrict trade margins to a percentage of that. Earlier it was thought that increasing the retail price would enable companies to give a higher margin in rupee terms, while complying with the percentage ceiling.

However, with the National Pharmaceutical Pricing Authority strictly enforcing the cap on annual price increase — 10% since early this year — on all medicines outside government price control, a cap in percentage terms is considered not prone to abuse.

December 02, 2007

Health ministry may hive off medical education into new department

In a move that could trigger a major debate among the medical fraternity, the government is reportedly toying with the idea of creating a separate department of medical education in the ministry of health and family welfare under a secretary level officer.

Coming just after the Presidential assent to the AIIMS (Amendment) Bill 2007, said sources familiar to the development, the proposed department is set to strangle the autonomy of Medical Council of India (MCI) and ignite fresh sparks in the ongoing ministry-medical fraternity tussle.

At present, MCI, a statutory body, regulates medical colleges, affiliation, new colleges and doctors registration.

According to the initial plans, the new department will be headed by a non-IAS secretary who may be picked up from the medical fraternity, sources close to the development told SundayET.

The new department is expected to handle regulatory and administration works related to medical education in the country. The sources further said that the creation of the new department was necessitated by the government’s conscious decision to allow more medical institutions on public-private partnership (PPP) mode.

Once the new department is created, the functioning of the country’s medical college-cum-hospitals, including All India Institute of Medical Sciences, Post Graduate Institute of Medical Education and Research and others, will be under two departments. “The health issues will be handled by the health department, and the issues related to the medical education of such hospitals will be administered by the proposed department of medical education,” said the sources.

Understandably, such a technical department — which may also oversee the education content of the medical institutes — will be headed by a health specialist. At present, there are 14 technocrat secretaries or equivalent to secretaries at the Centre who are not from any of the Central administration services.

Experts, however, feel the move could curtail the autonomy of MCI and strangle the autonomy of government institutions. “The idea looks good on paper, but what’s the need of a separate department when you have a fully functional Medical Council of India to look into medical education? Even the proposed appointment of a medical fraternity member as the secretary is of no consequence because eventually he has to report to the minister. I feel the move is one more attempt at curbing the autonomy of statutory bodies,” said Dr Ajay Kumar, president, Indian Medical Association (IMA).

Now, even as the move aims at co-opting the private sector to streamline the education system and meet the rapidly rising demand for medical professionals, the stage looks set for a fresh round of tussle.

December 01, 2007

New IRDA norms soon for health insurers

The Insurance Regulatory and Development Authority (IRDA) plans to soon come out with separate guidelines for health insurance players, aimed at comprehensive medical insurance coverage and redressal of consumer grievances.



“To handle a plethora of issues relating to health insurance with focussed attention, a separate health unit has been set up in the Authority; specialised resources have been inducted to strengthen the role of IRDA in the development and better conduct of health insurance business,” C.S. Rao, Chairman of IRDA, said at a conference organised by FICCI here on Thursday.

He also said that to increase the penetration of health insurance in the country, the Authority has recommended to the Government to bring down the capital requirement for stand-alone health insurance companies from the present Rs 100 crore to Rs 50 crore.

Rao also said that the committee constituted to look into the problems faced by senior citizens had submitted its report. “We are in the process of examining the report and taking further action on the recommendations that have been proposed,” he added.

The Authority, he said, had already taken steps towards standardising the definition of pre-existing diseases, which are now reflected in the health insurance products.

“The General Insurance Council, consisting of all-non life insurers, is also working to build a consensus on the issue,” the IRDA Chairman said.

The premium from health insurance products in non-life companies has grown from Rs 675 crore in 2001-02 to Rs 3,200 crore in 2006-07, while it has the potential to grow up to Rs 30,000 crore by 2015, Rao added.

November 26, 2007

Medicos of TN to go on ‘fast unto death’

Medicos of Government Medical colleges in Tamil Nadu have decided to go on ‘fast unto death’ from Friday after four days of protests failed to elicit a favourable response.

Medicos have been protesting since Monday this week articulating their grievances against the Union Health Ministry’s move to make a year’s service in rural areas compulsory for an MBBS degree.

After the first day of demonstrations, they started a relay fast that entered its third day on Thursday.

Two second year MBBS students of the Government Vellore Medical College (GVMC)--Jayasudha and Velvizhi--were admitted to the GVMC Hospital after they fainted on the third day of the fast. G.S. Rajesh, president of the Students’ Council, GVMC, said they were not opposed to rural service but only to the move to appoint MBBS graduates in rural areas on a salary of Rs.8000. There was no guarantee either that the job would be made permanent. Given the fact that most students, who hailed from poor families, would have to repay their educational loans on completion of their study, the offer of Rs.8000 would not be sufficient for them to repay their loan and make a living.

A pamphlet issued by the Tamil Nadu Medical Students Federation pointed out that as per the statistics furnished by the Ministry of Health and Family Welfare, Government of India, there were 2043 community health centres, 22842 primary health centres (PHCs) and 1,37,311 health sub-centres in the country.

While 13.3 per cent posts were vacant in the PHCs, the posts of 48.6 per cent surgeons, 47.9 per cent obstetricians and gynaecologists’ posts, 46.1 per cent general doctors’ posts and 56.9 per cent child specialists’ posts were vacant in the community health centres.

Under these circumstances, the compulsory one-year rural service would lead to 29,500 doctors being deprived of employment opportunities immediately and 40,000 junior doctors losing the chance of government jobs in another 10 years, it said.

Soon, get online MBBS degrees

Next year, if you fail to make it to a prestigious medical college, don't lose hope of studying medicine. A leading hospital chain is all set to offer India's first MBBS programme through distance education.

According to sources in the Medical Council of India which regulates medical education in the country, Max Healthcare and US-based Ocenia University have been in regular touch with MCI over the distance MBBS programme and their proposal is in the final stage of approval. Ocenia University offers online and distance medical programmes in the US and will help Max structure the course.

So far, only a few distance paramedical programmes are on offer in India by open universities like IGNOU as MCI is yet to approve online and distance programme in medicine. Since MBBS courses need a lot of hands-on training, distance courses were thought to be unviable.

Pervez Ahmed, executive director of medical operations at Max Healthcare, told TOI that the course and curriculum that Max plans to offer would be as per MCI guidelines and the mode of delivery would be similar to the Ocenia University programmes. "The theory part would be conducted in distance mode with interactive Internet tools. The practicals would be conducted on campus at various functional and upcoming Max Healthcare hospitals," he said.

Max Healthcare would be upgrading its six hospitals in the National Capital Region to 4,000 beds within three years, sources said. Anil Kohli, president of Dental Council of India, welcomed the plan for distance MBBS courses.

"This would definitely be a major boost to medical education and will make it within the reach of more students.

Currently, private medical courses are very costly and not properly monitored." According to Ahmed, the fees of the distance MBBS course would be "competitive."

November 24, 2007

Hiding medical history won't get you insurance: Supreme Court

Anyone not truthfully recording his past medical ailments in the application form seeking a life insurance cover could end up disentitling his kin from getting the promised amo-unt in the policy in case of his untimely death, the Supreme Court has ruled.

And this actually happened. One Chackochan did not mention a major operation for Andenoma thyroid, which he had undergone, in the life insurance policy application and died within five months of taking the policy. When his kin asked for the promised amount, Life Insurance Corporation (LIC) examined the medical records and found this serious lapse and cancelled the policy on the ground of hiding medical history.

The action of LIC was upheld by the apex court, which rejected the argument of the kin's counsel that the life insurance policy, being a requirement of social security, could not have been cancelled by LIC merely on the ground of suppression of medical history, especially when the corporation's doctor had examined the policy holder.

A Bench comprising Justices S B Sinha and H S Bedi said: “The purpose of taking a policy of insurance is not very material. It may serve the purpose of social security, but then the same should not be obtained with a fraudulent act by the insurer.”

Looking at the form in which Chackochan had stated that he had not undergone any operation and that his state of health has been good, the Bench said, “The proposer must show that his intention was bona fide. It must appear from the face of the record.”

It said a deliberate wrong answer, which has a great bearing on the contract of insurance, if discovered, might lead to the policy being vitiated by law.

“We are not unmindful of the fact that LIC, being a State within the meaning of Article 12 of the Constitution, its action must be fair, just and equitable but the same would not mean that it shall be asked to make a charity of public money, although the contract of insurance is found to be vitiated by reason of an act of the insured,” said Justice Sinha, writing the judgment for the bench.

If a person makes a wrong statement with knowledge of consequences thereof, he would ordinarily be not allowed to plead that disclosure of the suppressed facts would not materially alter the position, the court said rejecting the appeal filed by Chackochan's kin seeking the policy amount from LIC.

November 22, 2007

TN govt. signs MoU with private hospitals for financial assistance for children undergoin heart surgeries

The Tamil Nadu Government on Wednesday signed an MoU with 17 private hospitals in the state to perform heart surgeries for children belonging to indigent families.

As per the MoU, the State Government would extend a financial assistance of Rs 10,000 for closed heart surgery, Rs 30,000 for ordinary open heart surgery and Rs 70,000 for complex open heart surgery to be performed at private hospitals.

An official press release here said the number of children affected by heart diseases had been increasing due to changing lifestyle and food habits.Many children had been placed on waiting list to undergo surgery at Government hospitals.

Considering this, Chief Minister M Karunanidhi had announced a scheme to fund immediate surgery for children, below 12 years, at private hospitals, the release added.

Accordingly, the MoU was signed with the private hospitals, including Sri Ramachandra Hospital and Apollo Hospital here, in the presence of Karunanidhi at the Secretariat here.

Health village for medicare, research coming up near Chennai

A health village is to be established in Elavur, near Chennai, to serve as the hub for medicare and medical research in South Asia. It is a joint venture between Frontier Lifeline Hospital and the Tamil Nadu Industrial Development Corporation (TIDCO).

A memorandum of understanding, formalising the Rs. 450-crore project, was signed by representatives of the organisations on Wednesday in the presence of Chief Minister M. Karunanidhi.

Frontier Lifeline was represented by its founding chairman K.M. Cherian, and TIDCO, by its Managing Director S. Ramasundaram.

Electricity Minister Arcot Veeraswamy and Health Minister M.R.K. Panneerselvam were present along with Chief Secretary L.K. Tripathy.

The entire project will be completed in three phases over the next five years. Frontier Mediville, as the village is called, will also have a state-of-the-art national medical science park, which will facilitate research in basic and applied sciences, a multi-speciality 1,000-bed hospital, units of Indian systems of medicine, a vendors’ park and a medical university.

First of its kind


K.M. Cherian, founding chairman, Frontier Lifeline Hospitals, said it would fall under the category “bio-hospital,” first of its kind in the country, an emerging concept that combined clinical practice with regenerative medicine and basic sciences enhanced with holistic therapy. Frontier Mediville would also have a ‘Sterile Biomedical Corridor’ to facilitate manufacture of consumables, disposables and pharmaceutical products required for in-house hospital and research facilities.

This followed the Brazilian model, where the hospital generated products it required to run the entire unit, Dr. Cherian said.

The park would also be able to handle outsourcing orders from the rest of the world for tests, procedures and trials. Research and application of nano-technology and bio-informatics would be the frontier areas of exploration, he said.

Medical university

The comprehensive medical university would include a regional centre for nursing and paramedical training and would be run in collaboration with the Edward Dunlop Health Foundation, Australia. A herbarium was also on the cards, to be developed in collaboration with the Korean Research Institute of Bioscience and Biotechnology and the Asia Pacific Bio-Resources Consortium. It would house medicinal plants and develop genetically engineered strains, from which molecules could be extracted for therapeutic treatment.

“Our aim is to establish Frontier Mediville as a single-stop destination for any medical requirement. It will also serve as a holistic healing centre for medical tourists,” Dr. Cherian said at a press conference held after the MoU signing ceremony. He hoped that Frontier Mediville would evolve as a model for other States. The village would also be served by a helipad, a railway station and bus terminus to enhance accessibility to Elavur, located off National Highway 5.

November 19, 2007

Health screening: A business run on fear

Osteoporosis. Cancer. Heart attack. Pondering all the random, horrible ways we can get sick is enough to scare anyone stiff.

Hence the proliferation of new health screens--many not covered by insurance--that try to detect disaster early so patients can put up a decent fight. Screens differ from diagnostic tests in that screens are aimed at patients who are not at unusually high risk and exhibit no particularly alarming symptoms.

The problem: Plenty of screens don't really work that well. Many yield lots of false-positive results, which lead to unnecessary (and risky) treatments. Other tests work, though not in time for patients to act, leaving them to a life of endless dread.

"People forget that there are two sides to screening," says Dr Barbara Yawn, director of research at Olmstead Medical Center and a member of the United States Preventive Services Task Force, a government-backed group of health care professionals that study and evaluate health screens. "[Screens] can be beneficial, but there are always other risks."

Here's one horror story, from Dr. Robert Centor, dean of the Hunstville campus at the University of Alabama School of Medicine. Several years ago, during a simple diagnostic chest X-ray, Centor discovered a growth on the lung of one of his patients, who appeared to be in good health. He performed a biopsy to remove the nodule, which turned out to be benign. The patient, however, caught an infection at the hospital and died a few days later.

Despite the risks, health screens are on the rise. While no hard data exist, Yawn says the Preventive Task Force has been asked to review significantly more screenings in the past four years. Dr. David E. Bruns, director of clinical chemistry at the University of Virginia and editor of Clinical Chemistry, says he has seen an increase in the number of tests cited in his medical journal.

Health screening is a business run on fear. "If you find an issue of huge concern to the public and you can market peace of mind, particularly [with regard to] cancer or heart disease, people are willing to buy it," says Dr George Isham, chief health officer of HealthPartners, a health maintenance organization in Bloomington, Minn. "So you see a lot of tests pop up before there's good hard evidence of whether they work or not."

Indeed, the findings by the Preventive Services Task Force are under whelming at best: Of the 60 health screens the group has evaluated, it advises that physicians use only 29--and 10 of those, it says, should be done only at the physician's discretion.

Recommended tests are those that the Task Force believes deliver sufficient preventive value--net of false readings and the risks association with doing further procedures based on them. Some commonly recommended tests include Pap smears (to screen for cervical cancer in sexually active women), high blood-pressure tests, colorectal cancer screens and something called the Factor V Leiden test, which checks a person's predisposition to blood clots.

If a certain disease runs in the family, testing may be a no-brainer. In many other cases, the decision is anything but clear.

"Every advocacy group out there has a slightly different set of recommendations on screenings, so people get confused," says Isham. "Doctors and patients are getting conflicting messages about which tests to use."

Even recommended tests yield a scary number of false readings. Take mammograms, an often promoted and routine exam. According to research compiled by the US Agency for Healthcare Research and Quality, the percentage of false-positive readings is between 7% and 8% for women aged 40 to 59 who took the test. The figure drops to around 4% for women 60 to 79, mainly because the chances of getting breast cancer rise the older women get. If every woman between 40 and 59 in the US had a mammogram, a few million would be fretting unnecessarily over a wrong result.

When it comes to health screens, says Yawn, "it's really important to be honest with patients--what a test is likely to cost in terms of pain, angst and visits to the doctor."

The other problem: Many screens don't discover diseases in time to treat them. "It sounds great to catch cancer early, but it doesn't help unless you can treat it,” says Centor. “You need to be able to change life expectancy and possibly quality of life because of the diagnosis."

Which screens should you think twice about before having?

Perhaps the most dubious are "total body scans." These screens, performed using electron beam computerized tomography, are advertised as a tool that ferrets out cancers, heart disease, aneurysms, you name it. Many radiologists have set up freestanding businesses to peddle these scans.

In reality, the scans are more likely to pick up "incidentalomas"--blips that don't necessarily mean anything but require a follow-up test, says Dr. Roseanne Leipzig, professor of clinical and geriatric medicine at Mount Sinai School of Medicine.

According to recent research by G. Scott Gazelle, director of Massachusetts General Hospital's Institute for Technology Assessment, 90.8% of patients who had a full-body scan got a least one positive finding that led to additional testing. However, only 2% of those actually had a disease. Worse, these tests cost between several hundred and several thousand bucks--and most insurance companies won't pick up the tab.

Prostate-cancer screens create their own dilemmas too. These involve a blood test that looks for unusually high levels of prostate-specific antigens (PSAs). The American Cancer Society suggests men in their 50s take this test yearly (along with a digital rectal exam), but there are two potential flaws.

First, PSA levels generally increase with age and can be inflated because of more benign problems in the prostate, leading to false-positive results. Many men end up having unnecessary biopsies. Second, prostate cancer tends to grow very slowly, which means it might not kill you--or if it does, it will happen much later in life.

The calculation for patients: Skip the test and take your chances, or cut out the cancer early and risk post-surgery downsides like incontinence, impotence and a lot of discomfort.

Then there's the battery of computerized tomography scans. Since 2004, the National Cancer Institute has been conducting trials to see if CT scans (and standard chest X-rays) can reduce mortality in smokers by detecting lung cancer early. Sadly, there's little evidence thus far that supports this technique. In most cases, even with a CT scan, the cancer is found too late.

A full evaluation of the efficacy of CT scans will take at least several more years before any results are found. "These trials require such a large number of people because of the rareness of lung cancer in the overall population," says Isham. "It'll be some years before we have a conclusive answer on that. Good science takes a long time."

November 15, 2007

Corporates eye rural health centres

After setting up high-tech hospitals in cities corporates are now looking to the village. Healthcare giants such as the Hinduja group, Nicholas Piramal and Bombay Dyeing have approached the state government with proposals to manage some of its Primary Healthcare Centres (PHCs), say Mantralaya officials. PHCs are the equivalent of the neighbourhood clinic, where the government provides basic medical care, oversees surveillance and runs preventive camps.

While the state is "seriously considering" the public-private partnership (PPP) offers, healthcare activists have pointed out that primary health is the government's fundamental job and it cannot be leased.

"Corporates such as Hinduja, Bombay Dyeing and Nicholas Piramal have shown an interest in running PHCs. We are still fine-tuning how a PPP model would work," said Director General of Health Services Dr Prakash Doke. There are indications that the state may even consider a PPP model for its rural hospitals. On Monday, state health minister Vimal Mundada spoke at a health summit in Delhi about the need for all sectors—public, private and non-profit—to work together to "achieve ideal health parameters".

The trust-run Hinduja Hospital in Mahim has offered to run five PHCs in Raigad. Officials say the Nicholas Piramal group is looking at PHCs in the malnutrition-prone belt of Nandurbar while the Bombay Dyeing group is surveying PHCs around Pune.

Health activists, however, have voiced their reservations. "The provision of primary healthcare, especially to the poor, is the basic duty of the government. PPP can be used to provide something extra, for instance, to hire specialists such as anaesthetists or obstetricians in rural hospitals," says Dr Anant Phadke of the Jan Swasthya Abhiyan.

If a PHC begins to charge for its services (apart from the mandatory cost for preparing a case paper), the poor would stop using public health utilities, he adds.

But the PPP idea has caught on across India. If NGOs have adopted PHCs in Andhra Pradesh, the Gujarat government has joined hands with private groups under the Chiranjeevi Scheme to reduce maternal and infant deaths. In Haryana, a PPP titled the Vikalp Project caters to four far-flung districts. More recently, the Bihar government handed over several PHCs to the private sector. Dean of research and development at the Tata Institute of Social Sciences C A K Yesudian believes that the corporate interest in PHCs isn't a sustainable model as it depends on the business house's charity quotient rather than on a sustainable module. A PPP can only be useful if private players complement the government's functions. "The state should maintain its control while corporates could finance equipment or provide laboratory services," suggests Yesudian.

However, Dr Doke sees PPPs as a win-win situation. "We run 1,818 PHCs, of which private players will manage only a few to ensure better management and accountability," he says. He cites the example of Sastur in Osmanabad as a successful PPP initiative in Maharashtra.

State official believe that the shortage of specialists can be bridged with private participation. "We will explore options such as specialists visiting the PHC or initiating a referral system where poor villagers could seek cheaper treatment in hospitals run by these corporates," say officials.

Meanwhile, corporates say that their PHC foray is driven by charity not commerce. Hinduja Hospital, for instance, sees it as a CSR (Corporate Social Responsibility) initiative. CEO Pramod Lele told TOI that "we are likely to sign an MOU with the state in a week's time". Swati Piramal of the Nicholas Piramal group said they already have a pilot project in Rajasthan but she wasn't aware about the details in Maharashtra.

Corporates eye rural health centres

After setting up high-tech hospitals in cities corporates are now looking to the village. Healthcare giants such as the Hinduja group, Nicholas Piramal and Bombay Dyeing have approached the state government with proposals to manage some of its Primary Healthcare Centres (PHCs), say Mantralaya officials. PHCs are the equivalent of the neighbourhood clinic, where the government provides basic medical care, oversees surveillance and runs preventive camps.

While the state is "seriously considering" the public-private partnership (PPP) offers, healthcare activists have pointed out that primary health is the government's fundamental job and it cannot be leased.

"Corporates such as Hinduja, Bombay Dyeing and Nicholas Piramal have shown an interest in running PHCs. We are still fine-tuning how a PPP model would work," said Director General of Health Services Dr Prakash Doke. There are indications that the state may even consider a PPP model for its rural hospitals. On Monday, state health minister Vimal Mundada spoke at a health summit in Delhi about the need for all sectors—public, private and non-profit—to work together to "achieve ideal health parameters".

The trust-run Hinduja Hospital in Mahim has offered to run five PHCs in Raigad. Officials say the Nicholas Piramal group is looking at PHCs in the malnutrition-prone belt of Nandurbar while the Bombay Dyeing group is surveying PHCs around Pune.

Health activists, however, have voiced their reservations. "The provision of primary healthcare, especially to the poor, is the basic duty of the government. PPP can be used to provide something extra, for instance, to hire specialists such as anaesthetists or obstetricians in rural hospitals," says Dr Anant Phadke of the Jan Swasthya Abhiyan.

If a PHC begins to charge for its services (apart from the mandatory cost for preparing a case paper), the poor would stop using public health utilities, he adds.

But the PPP idea has caught on across India. If NGOs have adopted PHCs in Andhra Pradesh, the Gujarat government has joined hands with private groups under the Chiranjeevi Scheme to reduce maternal and infant deaths. In Haryana, a PPP titled the Vikalp Project caters to four far-flung districts. More recently, the Bihar government handed over several PHCs to the private sector. Dean of research and development at the Tata Institute of Social Sciences C A K Yesudian believes that the corporate interest in PHCs isn't a sustainable model as it depends on the business house's charity quotient rather than on a sustainable module. A PPP can only be useful if private players complement the government's functions. "The state should maintain its control while corporates could finance equipment or provide laboratory services," suggests Yesudian.

However, Dr Doke sees PPPs as a win-win situation. "We run 1,818 PHCs, of which private players will manage only a few to ensure better management and accountability," he says. He cites the example of Sastur in Osmanabad as a successful PPP initiative in Maharashtra.

State official believe that the shortage of specialists can be bridged with private participation. "We will explore options such as specialists visiting the PHC or initiating a referral system where poor villagers could seek cheaper treatment in hospitals run by these corporates," say officials.

Meanwhile, corporates say that their PHC foray is driven by charity not commerce. Hinduja Hospital, for instance, sees it as a CSR (Corporate Social Responsibility) initiative. CEO Pramod Lele told TOI that "we are likely to sign an MOU with the state in a week's time". Swati Piramal of the Nicholas Piramal group said they already have a pilot project in Rajasthan but she wasn't aware about the details in Maharashtra.

Wockhardt plans 14 new hospitals

Mumbai-based healthcare firm Wockhardt Hospitals is planning to set up 14 super-speciality hospitals across the country over the next two years, which could entail an investment of up to Rs 600 crore.

"We will almost double our hospitals by 2009 and would add more than 1,000 beds to the current 1,100 beds," a senior company official said here on the sidelines of CII Health Summit.

Asked about the investments, he said the company invests about Rs 55 lakh to Rs 60 lakh on each bed. It is planning to fund the expansion through the proceeds of its proposed Initial Public Offering (IPO), the official added.

The company is focusing on tier II and tier III cities such as Goa, Bhopal, Nagpur among others for expansion besides metros like Delhi, he said.

Wockhardt Hospitals Ltd has already filed its Draft Red Herring Prospectus (DRHP) with SEBI for its IPO. The company is issuing 30,000,000 equity shares of Rs 10 each through a book building process, which will constitute 28.77 per cent of the post issue paid-up capital of the company.

MedIndia Hospitals to launch rural voluntary health service

MedIndia Hospitals is launching a rural voluntary health service to screen the rural population of Tamil Nadu for digestive diseases and gastrointestinal cancers and offer subsidised treatment.

As part of the scheme, it is proposed to conduct free medical camps in rural areas to pick up these silent diseases at an early stage.

Poor and needy patients who are diagnosed with disease during the screening will be provided further investigations and treatment, excluding consumables and medicines, at a 30 per cent concessional rate.

The hospital has launched a helpline 09840993131 to advise the public on health and vaccination issues and to disseminate the services available under the voluntary health scheme. T. S. Chandrasekar, hospital chairman, said an estimated 3.5 per cent of the Indian population suffered from Hepatitis B virus and 1.5 per cent from Hepatitis C, both of which were silent killers. These hepatic infections could lead to permanent and serious liver damage.

According to World Health Organisation statistics, the incidence of digestive cancers ranged across esophagal cancer (11 per lakh of population), stomach cancer (7.5 per lakh), colon and rectal cancer (6.5 lakh) in men while in women the corresponding incidence of these diseases were 9 per lakh, 5 per lakh and 5.5 per lakh of population.MedIndia Hospitals has also commissioned a Video GI Manometry equipment to accurately detect motility disorders of the foodpipe and digestive system and to differentiate chest pain caused by heart disease and the food pipe.

The voluntary health scheme and the new facility were launched at a workshop on Saturday . MedIndia awards were also presented to senior teachers K.V. Thiruvengadam, S. Krishnan, V.I. Mathan, N. Rangabashyam, B. Krishna Rau and posthumously to Madanagopalan.

Chettinad Health City to be inaugurated next week

A non-profit arm of cement and construction major Chettinad Group is investing Rs 500 crore to set up Chettinad Health City, an integrated health care facility that includes medical education, patient care, research and community health initiatives. It is to be inaugurated on November 15.

This will be the country’s first non-profit health city venture. Others global health city initiatives include Aditya Birla Medicity, Pune and Apollo Health City, Hyderabad and Dubai Healthcare City, Dubai.

Conceived three years ago, the integrated tertiary referral CHC in Chennai will house all super-specialities, under a single roof, in phase three. “Though we are still in the investment phase, we are on-time as far as the project is concerned. We expect to complete the phase III by 2009, when we propose to have all super specialities and 1,000 beds for healthcare delivery,” CHC chief administrator N Venkat Phanidar told ET here on Saturday.

Promoted by the Rajah Sir Muthiah Chettiar Charitable and Educational Trust, Rs 250 crore investment has already been made into CHC. “We are still in the investment phase. Rather than tapping the boom in sectors like real estate and IT, our objective is to invest on a social asset. We also intend extending our facility to cover research and development and manufacturing activities, after meeting statutory compliance,” he said.

The idea is to be self-reliant in health care, as health care products like stents, are still import-driven. “We want to invest on knowledge and skills and nurture talent in health specialities,” he added.

Spanning an area of 100 acres, already an area of 12 lakh sq ft of construction has been completed. “CHC is replete with all the modern facilities. It houses a 600-bed hospital, a medical college and residential accommodation facility apart from outpatient amenities,” Mr Phanidar said. On the equipment side, Rs 40 crore has been invested, inclusive of the Rs 25 crore plus investment on cardiology department.

“CHC has three centres of excellence, institute of cardio-vascular diseases, institute of IVF and nephrology. We would like to improvise in phase II, where we propose to bring in specialities like cosmetics, neuroscience, ortho and ophthalmology. At a later stage, we would also like to bring in cancer speciality too,” he said
Of the 256 full-time doctors on CHC rolls, women constitute 40%. NRI-returned Dr R Ravi Kumar will spearhead the institute of cardiovascular disease.

Asked about the medical costs, Mr Phanidar said “our pricing will be competitive. Typically, our overall surgery costs will be 25% cheaper than those charged by hospitals in our category.”

A dialysis in CHC will be available for Rs 900, while the prevailing charges are Rs 1,500 outside. A bypass in CHC would mean a saving of at least Rs 30,000, he added.

CHC has a pact with Malaysia-based MasterSkill College of Nursing and Health, to train 120 students every two months. It is also negotiating with institutions from European countries and Australia. Its medical college, which has an annual intake of 150 students, is in the second batch, making 300 medicos available to CHC.

Knowledge panel for all-India entrance exam for MBBS

In a move that will affect lakhs of students across India, the National Knowledge Commission has asked the Centre to scrap state-level common entrance tests and conduct all-India entrance test for admission to medical colleges.

An NKC working group, which has comprehensively appraised the medical education system, has called for overhauling of the present system. "Policies of admission and fee structure of private colleges have to be regulated, not only to stop them from becoming sources of political and financial power, but also to arrest failing standards," NKC chairman Sam Pitroda told Prime Minister Manmohan Singh last week.

The group in its report, which is with TOI, has said, "There should be only one all-India common entrance test for all students who would like to get admissions to self-financing medical colleges. Since the CBSE-conducted examination for the 15% all-India quota in government medical colleges is taken by a large number of students, this appears to be an ideal examination, whose ambit can be expanded."

To make admissions transparent, the commission has said colleges must announce their fees in their prospectus, so that students can make their choice. Computers and IT should be used to increase transparency and efficiency in admission, examination, administration and teaching, it says.

More significantly, the group has sought an independent and standardised national exit examination at the end of four-and-half-year course to assess skills and knowledge acquired by students. This should be conducted immediately after the university examination and can also serve as a post-graduate entrance exam.

November 08, 2007

Medical education in digital form soon

Medical students in India could soon have the benefit of learning course content at their own pace through lectures that would be offered in a digital format.

Over 7,500 multimedia enhanced digital lectures subscribing to the curriculum prescribed by the Medical Council of India (MCI) for MBBS have been digitised.

For slow learners, the digital options offers the advantage of listening to the lectures repeatedly and learn. It can effectively supplement the faculty’s efforts at the medical colleges as well.

The Hyderabad-based e-learning company, Medical Education Research Centre (MEdRC), which has digitised the entire MBBS curriculum has entered into an agreement with Dr NTR University of Health Sciences, Vijayawada to provide digital curriculum.

The NTR University is introducing the digitised medical lectures on an experimental basis for the first three months. Based on the feedback from the students it would be extended, according to Dr Neeraj Raj, Managing Director of MEdRC. “What we have developed is an e-learning programme for undergraduate medical students. It consists of text, tables, flow charts, colour stills, 2D and 3D animation, audio, video of clinical methods, case discussions and video lectures by over 700 expert faculty from across the country”, he said.

The company has spent Rs 8 crore on the project so far. It is in talks with several Medical colleges to promote it.

Students to get health cards

All schoolchildren in India, above class V, will soon be screened for diseases once a year.

In a massive National School Health Programme being planned jointly by the ministries of health and HRD, children across the country will be given smart health cards containing information on their health. They will be screened by doctors, either from public or private hospitals, for blindness, deafness, dental and cardio vascular health, vitamin deficiencies and anaemia. If they are found suffering from any of them, they will be immediately referred for further treatment. The programme aims to promote health of schoolchildren, and prevent diseases by early diagnosis and treatment. Officials from both the ministries have already held talks with the next one scheduled for mid-December.

Health minister A Ramadoss said, "A deafness and speech programme will teach doctors, family members and teachers to identify children with hearing and sight problems early, before it becomes damaging. The school health programme will be a public-private partnership. The programme will be started initially in states which show interest in such a screening programme to protect the younger generation."

A similar programme is being run by state governments in Mizoram, Maharashtra, Tamil Nadu and Gujarat. "It needs to be a collective programme with states working in unison. Associations like the IMA and Dental Council of India have agreed to help us with the screening. Students would be given personal health cards, which would chart the disease history of the child concerned," Ramadoss added.

School-children will also be routinely screened for health complications like congenital heart disease and diabetes.

Risk factors like high blood pressure, hypertension and obesity among children, the primary causes behind cardio-vascular diseases (CVD), will also be identified for parents to better manage and avert impending diseases.

Nearly 10 years after the idea was first mooted, Planning Commission has approved in-principle India's first national programme for prevention and control of cardio-vascular diseases, stroke and diabetes. To be implemented and supervised by the health ministry, from mid-December, the initial phase will cost Rs 15 crore. "The success of the initial programme will help seal a total clearance from Planning Commission to the national programme. Under the programme, children will be regularly screened for diseases and risk factors. Anti-hypertensive drugs will cut down on high BP and lifestyle changes will cut down on obesity. WHO calls this programme a vital investment," a health ministry official told TOI.

The ministry has asked the plan panel to sanction Rs 1,680 crore to run the programme from 2008-2012.

Is the doctor-drug industry nexus harming patients?

Companies in the U.S. that produce drugs and medical devices with a turnover of more than $100 million may soon be forced to reveal the amount of money that they give to doctors to influence their prescribing patterns. A bill was recently introduced in the U.S. Senate to this effect. Already five States and the District of Columbia have such regulations in place.

What in the first place warrants a bill to make it mandatory for the drug industry to disclose such information?

It has been well known that the medicines that doctors often prescribe are the medicines that pharmaceutical companies want them to prescribe.

Off-label use


No matter that cheaper alternatives are available, that certain medicines prescribed are unnecessary, that the medicines are put to off-label use (for indications that the regulatory authorities have not approved them), doctors tend to do what the pharmaceutical companies have asked them to do.

So what has made many doctors lose their objectivity and become the front for the industry? “Free pens and pizza lunches. Sponsored conferences and compromised medical education… and unaffordable holidays,” an Editorial in the British Medical Journal (May 2003) points out.

Doctors may be getting free lunches, but in reality there is nothing called a free lunch. For all the gifts that the drug industry provides, the quid pro quo arrangement, though unstated, expects the doctors to prescribe more of the company’s medicines.

Funding education


In some countries, the industry starts influencing the doctors much earlier. According to an Editorial in the British Medical Journal (April 2005), “over half of all postgraduate medical education in the UK… is funded by the pharmaceutical industry.”

But rarely would doctors acknowledge or even agree that their prescribing decisions are indeed influenced by the industry. They would like us to believe that they are fiercely independent and that their prescribing trends are never influenced by the industry.

Patients would only love to believe that it is indeed so. After all, they pay a price for any biased prescription.

Rewarding doctors


But the facts point out otherwise. A paper published in the British Medical Journal in 2003 noted that the industry admitted to rewarding doctors for switching from one drug to another but maintained that it was a “standard industry practice.”

A paper published last year in the Journal of the American Medical Association (JAMA) states that the industry spends about $13,000 a year per doctor on marketing activities.

In all they spend more than $20 billion a year on marketing, about 90 per cent of which goes to doctors.

National survey


A paper published in the latest issue of the New England Journal of Medicine based on a national survey conducted in the U.S. notes that 35 per cent of the respondents have received reimbursement for “…costs associated with professional meetings or continuing medical education.” And 28 per cent received payments from the industry for “…consulting, giving lectures, or enrolling patients in trials.”

One may wonder that small gifts will not have any influence on their prescribing patterns But the JAMA report of 2006 states, “…the impulse to reciprocate for even small gifts is a powerful influence on people’s behaviour.”

That has been the basis for many institutions in the U.S. for not allowing sales representatives inside their institutions or the companies from providing free lunches to doctors in their campuses. More institutions are joining the fray.

While an institution-level policing may have worked successfully, making the companies reveal information on doctor funding has been far from successful. For instance, Minnesota, which was the first State in 1993 to have such a disclosure law in place, and Vermont require the information to be publicly available.

Not accessible


But a study published in JAMA (March 2007) found that accessing information was not as easy as it was originally intended to be. It found that in Vermont about 60 per cent of the payments made by the companies were not released to the public.

And the reason? “…Pharmaceutical companies designated them as trade secrets,” the study revealed. And it was not that the information accessible revealed all. About 75 per cent of publicly disclosed payment information did not identify the recipient.

If some of the leading medical journals, and not legislations, compelled the pharmaceutical companies to register human clinical trials for consideration of results publication, probably patient groups would be able to do the same with the disclosure laws.

One more platform


Alas, most patient groups themselves depend on pharmaceutical companies for funding and they act as yet another platform for the companies to sell their products!

With only a few potential blockbuster drugs produced in the recent past and with fierce competition in the market, companies are forced to milk the most out of the existing drugs. How far the legislation will be able to cleanse the system will be closely watched by other countries.

Is the doctor-drug industry nexus harming patients?

Companies in the U.S. that produce drugs and medical devices with a turnover of more than $100 million may soon be forced to reveal the amount of money that they give to doctors to influence their prescribing patterns. A bill was recently introduced in the U.S. Senate to this effect. Already five States and the District of Columbia have such regulations in place.

What in the first place warrants a bill to make it mandatory for the drug industry to disclose such information?

It has been well known that the medicines that doctors often prescribe are the medicines that pharmaceutical companies want them to prescribe.

Off-label use


No matter that cheaper alternatives are available, that certain medicines prescribed are unnecessary, that the medicines are put to off-label use (for indications that the regulatory authorities have not approved them), doctors tend to do what the pharmaceutical companies have asked them to do.

So what has made many doctors lose their objectivity and become the front for the industry? “Free pens and pizza lunches. Sponsored conferences and compromised medical education… and unaffordable holidays,” an Editorial in the British Medical Journal (May 2003) points out.

Doctors may be getting free lunches, but in reality there is nothing called a free lunch. For all the gifts that the drug industry provides, the quid pro quo arrangement, though unstated, expects the doctors to prescribe more of the company’s medicines.

Funding education


In some countries, the industry starts influencing the doctors much earlier. According to an Editorial in the British Medical Journal (April 2005), “over half of all postgraduate medical education in the UK… is funded by the pharmaceutical industry.”

But rarely would doctors acknowledge or even agree that their prescribing decisions are indeed influenced by the industry. They would like us to believe that they are fiercely independent and that their prescribing trends are never influenced by the industry.

Patients would only love to believe that it is indeed so. After all, they pay a price for any biased prescription.

Rewarding doctors


But the facts point out otherwise. A paper published in the British Medical Journal in 2003 noted that the industry admitted to rewarding doctors for switching from one drug to another but maintained that it was a “standard industry practice.”

A paper published last year in the Journal of the American Medical Association (JAMA) states that the industry spends about $13,000 a year per doctor on marketing activities.

In all they spend more than $20 billion a year on marketing, about 90 per cent of which goes to doctors.

National survey


A paper published in the latest issue of the New England Journal of Medicine based on a national survey conducted in the U.S. notes that 35 per cent of the respondents have received reimbursement for “…costs associated with professional meetings or continuing medical education.” And 28 per cent received payments from the industry for “…consulting, giving lectures, or enrolling patients in trials.”

One may wonder that small gifts will not have any influence on their prescribing patterns But the JAMA report of 2006 states, “…the impulse to reciprocate for even small gifts is a powerful influence on people’s behaviour.”

That has been the basis for many institutions in the U.S. for not allowing sales representatives inside their institutions or the companies from providing free lunches to doctors in their campuses. More institutions are joining the fray.

While an institution-level policing may have worked successfully, making the companies reveal information on doctor funding has been far from successful. For instance, Minnesota, which was the first State in 1993 to have such a disclosure law in place, and Vermont require the information to be publicly available.

Not accessible


But a study published in JAMA (March 2007) found that accessing information was not as easy as it was originally intended to be. It found that in Vermont about 60 per cent of the payments made by the companies were not released to the public.

And the reason? “…Pharmaceutical companies designated them as trade secrets,” the study revealed. And it was not that the information accessible revealed all. About 75 per cent of publicly disclosed payment information did not identify the recipient.

If some of the leading medical journals, and not legislations, compelled the pharmaceutical companies to register human clinical trials for consideration of results publication, probably patient groups would be able to do the same with the disclosure laws.

One more platform


Alas, most patient groups themselves depend on pharmaceutical companies for funding and they act as yet another platform for the companies to sell their products!

With only a few potential blockbuster drugs produced in the recent past and with fierce competition in the market, companies are forced to milk the most out of the existing drugs. How far the legislation will be able to cleanse the system will be closely watched by other countries.

November 06, 2007

Overseas Doctors seeking to work in Australia falls by 90%: The Haneef Effect

The number of overseas doctors seeking to work in Australia has fallen by 90 per cent because of the government’s handling of the case against Mohammed Haneef, a medical association said.

“This spells disaster for an already over-stretched and under-resourced medical work force — particularly for rural and regional areas where many of these doctors are posted,” said Nagamma Prakash of the Overseas and Australian Medical Graduates Association.

Haneef, an Indian doctor, was detained for weeks in connection with failed UK bombings on allegedly flimsy evidence before being allowed to fly home.

Prakash spoke of “growing anger among Australians of Indian background” at the government’s handling of the case.

Health insurance takes root in Orissa village

At the time when over 200 people died of cholera in southern Orissa's Rayagada, Koraput and Kalahandi districts recently, the deadly virus did not enter villages in the neighbouring villages of Gajapati district.

The virus did not spread into the villages of at least five blocks of Gajapati district as the tribal villagers are well-informed in their health care, thanks to the People's Rural Health Promotion Scheme, an integrated health insurance launched by the People's Rural Education Movement (PREM) in association with Plan International.

The scheme was launched 4 years ago to provide medical services, as well as health insurance to tribals and fishermen of the operational areas of PREM with a minimum and one time premium.

Praising the scheme the International Labour Organisation says, “Preventive health care programme of PREM-Plan and peripheral care offered through Village Medicine Depots help to reduce referral morbidity and thereby reduce the expenditure load on PRHPS.”

Under the scheme, if a patient suffers from any disease, he is first treated at the Village Medicine Depot set up by the organisation. A trained lady from the respective village is appointed to provide medicine to the patient for minor ailments. After three days, if there is no improvement, the patient is referred to the nearest Public Health Centre and to the medical college at Berhampur.

At the VMD, the treatment is given for at least 15 minor diseases including fever, malaria, diarrhoea, dehydration, minor injuries, cough, scabies, safe delivery and immunisation. The quality and low-cost medicines are stocked in the VMD. Trained women of the respective villages serve the medicine with elaborate health advice on sanitation and hygiene.

In order to insure his health, a person has to be enrol his or her name under the scheme paying Rs 30. The fund collected from the members becomes a corpus and managed by the villages themselves. “Our role is very limited as the scheme is operated by the villagers themselves,” said PREM president, Jacob Thundiyil.

The scheme is presently operating in 333 villages under 4 blocks — Mohana, Nuagada, Gumma and Rayagada in Gajapati district, 144 villages in 3 blocks — Krushnaprasad, Bramhagiri and Kakatpur in Puri district and covers over 80,000 people.

“We are planning to extend the scheme to Gunupur block in Rayagada district, Sanakhemundi and Dharakote blocks in Ganjam district and Vizianagaram district in Andhra Pradesh and to cover another 40,000 people,”he said.

The organisation has been provided some infrastructural facilities in all the referral government hospitals including the MKCG Medical College and Hospital, Berhampur for better treatment to their insured patients.

In MKCG Medical College and Hospital, PREM was donated at least 15 beds in the Orthopedic department.

“We never refer to any patients to the private nursing homes" he said. In this way we teach the people about the access to the government hospitals,” he added.

All the referral ad treatment expenditure will be borne by the organisation if the patient is enrolled under the scheme.

“The distance from our village to PHC is about 10 km while the district hospital and medical college are about 40 km and 160 km away respectively. Serious cases are taken to Paralakhemundi district hospital by bus or tractor. From the insurance we are being reimbursed the cost of the medicines,” said Digu Digal of Sadanga in Gumma block of Gajapati district.

“In our village one person had gone through a stomach operation, another person had a paralytic stroke. The scheme helped both the cases,” said Janab Majhi of Paleri village of the same district.

Jacob, the founder of the scheme said the People’s Rural Health Promotion Scheme was aimed at breaking the link between ill-health and poverty by ensuring the health care of the tribal and fishermen who are the focal groups of PREM-Plan’s development activities.

The scheme is embedded in the other health and development activities of PREM-Plan. He was influenced by other community health insurance schemes of RAHA in Chattisgarh and ACCORD in Tamil Nadu to launch the scheme with improvisations for the project areas of the organisation.

UK docs oppose curbs on Indians

Britain's medical community has resoundingly voted to oppose the government's proposal to restrict the employment opportunities for Indian and other non-European Union doctors in the National Health Service (NHS).

In a survey conducted by the British Medical Association (BMA) this week, members voted to oppose tighter restrictions on the employment opportunities of overseas doctors and medical students.

Britain's Health Minister Ben Bradshaw has recently drawn up proposals to slash the number of junior doctors from overseas coming to Britain to train. The idea is to preserve jobs for the rising number of British medical graduates.

The proposal is that doctors from countries outside the EU should not be considered for a job unless there are no qualified applicants from Britain or from elsewhere in Europe. This is an unlikely scenario given the popularity of medical training in Britain and the EU.

During the recent rounds of recruitment to the NHS, several hundred British doctors who could not find employment left the country as the issue snowballed into a major public controversy through demonstrations and petitions.

There is also a proposal that fresh British medical graduates would automatically get a first-year hospital training place on graduation, which would give them a head start over even other European candidates.

But BMA's survey released at a conference this week revealed that almost two-thirds (64 percent) of the 737 doctors and medical students surveyed believe that overseas students graduating from UK medical schools should not be prevented from competing for training jobs.

Over half (57.4 percent) think that doctors who qualified overseas should be entitled to compete for training posts with UK graduates, although most of these thought that this should apply only to those already working in the NHS.

Hamish Meldrum, chairman of council at the BMA, said: "The government has made a mess of medical training. It appears they are now trying to penalise the thousands of overseas doctors and medical students who want to work in the NHS."

Other key findings of the survey include: Half of respondents oppose the idea of a national computerised examination on entry to core specialist training; Eight in 10 respondents agree with recommendations that medical career structures should be the same across the UK

In a separate submission to the Department of Health's consultation on proposals to restrict employment opportunities to overseas doctors, the BMA said the proposals were 'unfair'.

The BMA said in its submission that "medical immigration" should be better controlled in future, but was concerned for the welfare of thousands of doctors and medical students from overseas who are already in the UK.

Terry John, chair of the BMA's International Committee, said: "Long-term, the UK should be able to produce its own medical workforce and managing medical immigration in the future will be necessary.

"However, the thousands of overseas junior doctors currently providing essential services in UK hospitals must not be scapegoated for the government's poor workforce planning. They came to the UK in good faith, and the honest expectation of training opportunities in the NHS."

The BMA is particularly concerned about overseas students currently spending large amounts of money - an average of 23,000 pounds a year during their clinical years - to study at UK medical schools.

John added: "International medical students are often making huge personal and financial sacrifices in order to study in the UK. If they are not allowed to apply for postgraduate training posts, and are forced to return home, they could face a huge struggle in repaying outstanding debts."

The BMA said it was aware that this would also adversely affect UK medical schools, which rely heavily on income from overseas students.

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