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As of April 22, 2020, Sikkim does not have any confirmed cases of COVID-19. As of April 21, 2020, 87 samples have been sent for testing from Sikkim. Of these, 80 have tested negative for COVID-19, and the results of seven samples are awaited. The state has announced several policy decisions to prevent the spread of the virus and provide relief for those affected by it. In this blog post, we summarise some of the key measures taken by the Sikkim state government in this regard as of April 22, 2020.
Response before national lockdown
On March 16, the state government responded to the growing number of suspected cases in India by notifying certain directions to be applicable till April 15, 2020. These included: (i) banning the entry of all domestic and foreign tourists in to the state, (ii) closing all educational institutes and anganwadis, (iii) prohibiting the use of recreational facilities such as, casinos, gym, and cinemas, (iii) closing three out of five check posts (border opening) for all visitors in to the state and opening the other two only for medical and police teams, and (iv) banning private industries from getting migrant workers from outside the state and avoiding large concentration of workers at one place.
On March 19, assembly of more than five people was prohibited in the state until April 15, 2020. The government ordered the suspension of all non-essential work on March 19. The supply of all essential commodities such as food grains, vegetables, sanitisers and masks was allowed. Further, the formation of a sub-divisional task force to detect suspected cases was ordered.
On March 22, the government regulated intra-state movement of private vehicles, two-wheelers and taxis on an odd-even basis (allowing plying of vehicles on alternate days as per the number plate) until April 15, 2020. The government also reduced the budget session of the state to two days on March 23.
On March 25, the central government announced on a 21-day country-wide lockdown till April 14. During the lockdown the state government took various steps for physical containment, health, financial and welfare measures. These are detailed below.
Measures taken during lockdown
Movement Restrictions
Certain movement restrictions were put across the state. These include:
Essential Goods and Services
On April 5, the state government issued an order requiring establishments such as shops, hotels, private offices, and commercial establishments to remain closed until April 15. Establishments which were permitted to remain functional include law enforcement agencies, health services, electricity and water services, petrol pumps, and media. Shops for PDS, groceries, vegetables, milk and, medicines were only allowed remain open from 9 am to 4 pm.
Health Measures
On March 31, the Sikkim government identified and set up dedicated isolation wards and treatment centres in the STNM hospital, Sochakgang as a precautionary measure. The government also issued directions for citizens to avoid getting infected by coronavirus. These included social distancing, and maintaining proper hygiene.
On April 18, the state government made it mandatory for all the public, students, teachers, and government employees, to install the Aarogya Setu application. The government of India launched a mobile app called ‘Aarogya Setu’ to enable people to assess the risk of catching COVID-19 on April 2, 2020. The app uses Bluetooth and Global Positioning System (GPS) based device location for contact tracing in order to prevent the spread of COVID-19.
Welfare Measures
Certain relaxations after 20th April
On April 14, the nation-wide lockdown was further extended till May 3, 2020. On April 15, the Ministry of Home Affairs issued guidelines outlining select activities which will be permitted from April 20 onwards. These activities include health services, agriculture related activities, certain financial sector activities, operation of Anganwadis, MNREGA works, and cargo movement. Further, subject to certain conditions, commercial and private establishments, industrial establishments, government offices, and construction activities will also be permitted. The Sikkim government took the following steps in the same line.
For more information on the spread of COVID-19 and the central and state government response to the pandemic, please see here.
The National Medical Commission (NMC) Bill, 2017 was introduced in Lok Sabha in December, 2017. It was examined by the Standing Committee on Health, which submitted its report during Budget Session 2018. The Bill seeks to regulate medical education and practice in India. In this post, we analyse the Bill in its current form.
How is medical education and practice regulated currently?
The Medical Council of India (MCI) is responsible for regulating medical education and practice. Over the years, there have been several issues with the functioning of the MCI with respect to its regulatory role, composition, allegations of corruption, and lack of accountability. For example, MCI is an elected body where its members are elected by medical practitioners themselves, i.e. the regulator is elected by the regulated. In light of such issues, experts recommended nomination based constitution of the MCI instead of election, and separating the regulation of medical education and medical practice. They suggested that legislative changes should be brought in to overhaul the functioning of the MCI.
To meet this objective, the Bill repeals the Indian Medical Council Act, 1956 and dissolves the current Medical Council of India (MCI) which regulates medical education and practice.
Who will be a part of the NMC?
The NMC will consist of 25 members, of which at least 17 (68%) will be medical practitioners. The Standing Committee has noted that the current MCI is non-diverse and consists mostly of doctors who look out for their own self-interest over larger public interest. In order to reduce the monopoly of doctors, it recommended that the MCI should include diverse stakeholders such as public health experts, social scientists, and health economists. In other countries, such as the United Kingdom, the General Medical Council (GMC) responsible for regulating medical education and practice consists of 12 medical practitioners and 12 lay members (such as community health members, and administrators from the local government).
How will the issues of medical misconduct be addressed?
The State Medical Council will receive complaints relating to professional or ethical misconduct against a registered doctor. If the doctor is aggrieved by the decision of the State Medical Council, he may appeal to the Ethics and Medical Registration Board, and further before the NMC. Appeals against the decision of the NMC will lie before the central government. It is unclear why the central government is an appellate authority with regard to such matters.
It may be argued that disputes related to ethics and misconduct in medical practice may require judicial expertise. For example, in the UK, the GMC receives complaints with regard to ethical misconduct and is required to do an initial documentary investigation. It then forwards the complaint to a Tribunal, which is a judicial body independent of the GMC. The adjudication and final disciplinary action is decided by the Tribunal.
What will the NMC’s role be in fee regulation of private medical colleges?
In India, the Supreme Court has held that private providers of education have to operate as charitable and not for profit institutions. Despite this, many private education institutions continue to charge exorbitant fees which makes medical education unaffordable and inaccessible to meritorious students. Currently, for private unaided medical colleges, the fee structure is decided by a committee set up by state governments under the chairmanship of a retired High Court judge. The Bill allows the NMC to frame guidelines for determination of fees for up to 40% of seats in private medical colleges and deemed universities. The question is whether the NMC as a regulator should regulate fees charged by private medical colleges.
A NITI Aayog Committee (2016) was of the opinion that a fee cap would discourage the entry of private colleges, therefore, limiting the expansion of medical education. It also observed that it is difficult to enforce such a fee cap and could lead medical colleges to continue charging high fees under other pretexts.
Note that the Parliamentary Standing Committee (2018) which examined the Bill has recommended continuing the current system of fee structures being decided by the Committee under the chairmanship of a retired High Court judge. However, for those private medical colleges and deemed universities, unregulated under the existing mechanism, fee must be regulated for at least 50% of the seats. The Union Cabinet has approved an Amendment to increase the regulation of fees to 50% of seats.
How will doctors become eligible to practice?
The Bill introduces a National Licentiate Examination for students graduating from medical institutions in order to obtain a licence to practice as a medical professional.
However, the NMC may permit a medical practitioner to perform surgery or practice medicine without qualifying the National Licentiate Examination, in such circumstances and for such period as may be specified by regulations. The Ministry of Health and Family Welfare has clarified that this exemption is not meant to allow doctors failing the National Licentiate Examination to practice but is intended to allow medical professionals like nurse practitioners and dentists to practice. It is unclear from the Bill that the term ‘medical practitioner’ includes medical professionals (like nurses) other than MBBS doctors.
Further, the Bill does not specify the validity period of this licence to practice. In other countries such as the United Kingdom and Australia, a licence to practice needs to be periodically renewed. For example, in the UK the licence has to be renewed every five years, and in Australia it has to renewed annually.
What are the issues around the bridge course for AYUSH practitioners to prescribe modern medicine?
The debate around AYUSH practitioners prescribing modern medicine
There is a provision in the Bill which states that there may be a bridge course which AYUSH practitioners (practicing Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) can undertake in order to prescribe certain kinds of modern medicine. There are differing views on whether AYUSH practitioners should prescribe modern medicines.
Over the years, various committees have recommended a functional integration among various systems of medicine i.e. Ayurveda, modern medicine, and others. On the other hand, experts state that the bridge course may promote the positioning of AYUSH practitioners as stand-ins for allopathic doctors owing to the shortage of doctors across the country. This in turn may affect the development of AYUSH systems of medicine as independent systems of medicine.
Moreover, AYUSH doctors do not have to go through any licentiate examination to be registered by the NMC, unlike the other doctors. Recently, the Union Cabinet has approved an Amendment to remove the provision of the bridge course.
Status of other kinds of medical personnel
As of January 2018, the doctor to population ratio in India was 1:1655 compared to the World Health Organisation standard of 1:1000. The Ministry of Health and Family Welfare stated that the introduction of the bridge course for AYUSH practitioners under the Bill will help fill in the gaps of availability of medical professionals.
If the purpose of the bridge course is to address shortage of medical professionals, it is unclear why the option to take the bridge course does not apply to other cadres of allopathic medical professionals such as nurses, and dentists. There are other countries where medical professionals other than doctors are allowed to prescribe allopathic medicine. For example, Nurse Practitioners in the USA provide a full range of primary, acute, and specialty health care services, including ordering and performing diagnostic tests, and prescribing medications. For this purpose, Nurse Practitioners must complete a master’s or doctoral degree program, advanced clinical training, and obtain a national certification.
