NEXT and outcomes-based policy making

The recently passed National Medical Commission (NMC) Act in India has an interesting provision for a common National Exit Test (NEXT) to certify medical students for successful completion of their basic graduation course and license them to practice medicine as well as admission to post-graduate courses. The government also claims that the Act will dispense with the elaborate system of regulations and inspections that the Medical Council of India (MCI) undertakes that had become a source of rampant corruption.

The underlying presumption is that instead of validating  adherence to procedural requirements by medical colleges, focus on certifying the quality of graduates being trained. In other words, focus on capturing the outcomes. Why fuss on regulations and inspections with their messy administration and governance challenges when we can just monitor the quality of exiting students?

This resonates strongly with the logically appealing narrative of outcomes-based policy making, one of the prevailing fads in international development. There is something neat about this - just define outcomes, and leap-frog the messy procedural and governance challenges that have bogged us down for decades.

My own thinking on it has evolved considerably over the past decade or so, and today I am less convinced about neat outcomes-based policies. Accordingly, I have blogged earlier about why outcomes-based policies, especially on complex issues, while deceptively alluring, but are most likely to disappoint. See this, this, this and this.

The stakes are too high, the political economy too complex, and the eco-system constraints too onerous for a NEXT to achieve its desired objective in such a simple manner. For a start, the nature of NEXT itself poses massive implementation challenges. For NEXT to be meaningful, it will have to go beyond the easily administrable Multiple Choice Questions (MCQs) and involve qualitative assessment, including for clinical judgement skills. Unlike MCQs, such testing has too many moving parts, thereby, increasing the likelihood of subversion, even with use of the best technologies. 

If the fidelity of the exam processes itself is not illegally subverted, then the nature of questions or the manner of its administration (the rules of the game) will be legally compromised. And if neither happens and NEXT forces the closure of many medical colleges, or results in failures of large numbers of students (especially those who have paid massive sums under the management quota), or abruptly denies the several influential people who want their children as doctors, then vulnerabilities will only accumulate inexorably. 

In any case, it is naive to expect a simple outcomes-tweak, howsoever rigorously monitored, to force the managements and systems of the 536 medical colleges to start adhering to all requirements in a manner that enables high-level graduate instruction. For there is also the issue of supply-side requirements. We under-estimate the physical infrastructure and personnel quality requirements as well as pedagogy approaches that are critical to ensuring quality in medical graduate instruction.  

Then there is the student feedstock quality itself - we have seen how NEET or JEE have been distorted by the entrance coaching institutions, thereby seriously undermining the quality of entrants into professional courses. NEXT coaching centres will inevitably spring up. Finally, there are the likely serious emergent anomalies and problems (say, those related to reservation etc) which are not easily addressed. Resolving all these take time and persistent effort.

This is not to reject NEXT, but only to qualify the requirements to achieve the objective. For the NEXT to stand any chance of success in ensuring good quality of medical graduates, the exit test has to be complemented with all the governance requisites - basic and easily verifiable eligibility requirements for the institutions (entrance examination, its physical and personnel infrastructure, and course modules), transparent and arms-length accreditation and periodic certification/ranking mechanism, and a light-touch regulator. There is no substitute for these latter requirements. And more than NEXT, it is this that would still remain the biggest challenge.

Admittedly, the details of the regulations on the NMC Act and its operationalisation, and how the NMC itself would acquit itself as a regulator are what would matter. The battle has only started. In many ways, even with NEXT, the main challenges to be overcome are pretty much the same that the erstwhile Indian Medical Council (IMC) failed to administer - governance and regulation.

The worst outcome would be to gloss over the more persistent governance and regulation battles and prematurely declare victory in the belief that the mere introduction of NEXT (even if implemented with high fidelity) would help achieve the objective of quality in medical graduation in India.