Autonomy for Medical Institutes in India: A view from history

‘… where the patience of the oppressed invites the oppressor to repeat his injuries. ’

—Thomas B. Macaulay^[1]

In India, the interlinked questions of government control of medical research institutes and institutional autonomy have been contentious issues since colonial times when several of the country's bacteriological laboratories and medical institutes were established. Institutional autonomy for academic and research institutes may be broadly understood to mean minimal or even the absence of government and bureaucratic interference in directing institutional affairs such as those relating to framing rules and regulations pertaining to the institution; recruitment; academic programmes; research funding and limited official or government appointees to the governing board (GB) through whom the government is likely to exercise its control. This does not, however, mean the complete absence of government regulation but that institutional autonomy is best guaranteed by restricting the power and authority of the government and the civil bureaucracy to oversee institutional affairs, thereby protecting professionals managing and working in an institution from an oppressive dependence on the government.

After independence in August 1947, the All India Institute of Medical Sciences (AIIMS), New Delhi—India's premier medical institute—was among the new medical institutes created. It provides for an interesting case study of institutional autonomy for medical institutes. The AIIMS was created by an Act of the Indian Parliament (1956) giving it a statutory status that was expected to grant and guarantee it autonomy that none of the other medical institutes enjoy. It was kept outside the jurisdiction of the Medical Council of India (MCI) and the Indian Council of Medical Research (ICMR). It was planned as a university-level postgraduate institute to provide medical education and research of international standards. Today, it serves as a model for similar institutes being established elsewhere in India.

Over the years, however, AIIMS has had to countenance a variety of challenges that have cast doubts on its autonomous status. Some of these challenges indicate that there is a gap between statutory provisions, government pledging institutional autonomy and actual experience of those heading and managing the AIIMS. For instance, in AIIMS the selection committee for deans comprises only bureaucrats and the health minister but no doctors.^[2] The complications arising from such iniquitous relationship between the government, the institute head and medical professionals associated with it manifested in the 2006 episode involving the then Union health minister and president of AIIMS Dr A. —amadoss and director of AIIMS Dr P. Venugopal, over the appointments of the deputy director and the dean.^[3] Nothing highlights the problems arising from such a situation better than an observation from a former director of an Indian Institute of Technology (IIT) who contrasted the difference between the IITs, also created by a Parliamentary Act in 1956, and AIIMS, observing that the absence of ‘power brokers’, ‘politicians and bureaucrats wearing two hats simultaneously’ in the meetings of the GB of the IITs gives the members the freedom for open and objective discussions and rational but responsible decision-making which is not the case with AIIMS.^[2] This comment was made much before the more recent controversies related to the IITs but illustrates the extent to which government interference can go.

In this article, I examine the debates on the AIIMS Bill in the Indian Parliament with specific reference to the assorted queries raised and range of issues deliberated upon pertaining to those provisions of the Bill that had a bearing on diverse aspects of institutional autonomy. I examine the understanding, perceptions and attitudes of the participating Members of Parliament (MPs) towards autonomy for independent India's leading medical institute at the time of its founding. The article shows that, notwithstanding the rhetoric and assurances to the contrary by ministers of health at different times to the Parliament, autonomy has eluded AIIMS and the bureaucratic and political sway of government departments over it is well entrenched. I also describe where and how the breach in autonomy occurs. Before doing so, I briefly recapitulate the status of medical institutes during the colonial period suggesting certain continuity in the post-independent years. I revisit the past to understand better the present and the future of the existing institute and similar future institutes. Although I do not delve into questions of nature and quality of medical research in India, it is expected to help readers acquaint better with a major hindrance to doing medical research in India.

The Colonial Period

Under colonial rule the administration of public health was decentralized to provincial and local governments. Medical research was an imperial preserve with the Central government retaining control over bacteriological laboratories, medical research institutes and the medical research department.^{[4],[5],[6],[7]} This constitutional division was retained even after independence. Medical research during the colonial period was defined by a military orientation and political and racial exclusiveness in the location of medical institutes, recruitment of senior staff, and funding. The GBs of medical research institutes were mainly composed of officials and government nominees many of whom were British members of the government's Indian Medical Service (IMS).^{[4],[5],[6],[7],[9]}

In 1911, the Indian Research Fund Association (IRFA) was founded by Sir Pardey Lukis, Director General of the IMS with a view to organize a group of trained men for medical research, which would not require the sanction of the Secretary of State for India sitting in London for its work and the approval of the legislative assemblies in India for its funding. To further ensure autonomy and restrict government interference a Scientific Advisory Board was constituted to advise on technical matters but the real control remained vested in the GB, which initially consisted only of the Director General of the IMS and the Public Health Commissioner (PHC), both government officials. Independent Indian medical professionals and university medical faculties had no representation and say in the GB. The IRFA's funding of medical research was skewed almost exclusively in favour of government research institutes dominated by IMS officers and hardly contributed anything to the universities where Indian professors were located. All this generated great dissatisfaction in the Indian medical profession.^{[4],[5],[6],[7],[8],[9]}

In the 1920s, non-IMS Indian medical professionals supported by the Indian nationalist leadership demanded representation for non-official Indian doctors and scientists on the interlinked GBs of the IRFA, the Walter Fletcher Committee (1926) proposed Central Medical Research Institute and the Rockefeller Foundation (RF)-sponsored All India Institute of Hygiene and Public Health (AIIHPH). This brought them into conflict with British members of the IMS. David Arnold suggests this tussle needs to be viewed in the context of ‘a highly politicized struggle for patronage and authority’ in which he notes, ‘a recurrent tension between the “political” and the “scientific”.’^[4] IMS officers expressed fear that Indian representation would politicize medical institutes to the detriment of medical research and argued for ‘scientific control’ over research funding and institutions as the only means to keep out political influence and ensure institutional autonomy.^{[4],[5],[6],[7]} Pratik Chakrabarti suggests that the plea for autonomy for the Central institute was essentially a ploy to retain medical research in British hands.^[7] The various controversies of this time had unfortunate consequences as evident from the experience of the AIIHPH.

The AIIHPH was inaugurated in 1932 but by 1938 it appeared to have suffered deterioration having deviated from its original goal of being a university-style postgraduate institute. Both the colonial and RF authorities were concerned and in 1939 appointed John Grant, RF officer and professor of Public Health at the Peking Union Medical College as director. Reporting on the many hurdles he faced in re-organizing the institute, he pointed out how the Scientific Advisory Board constituted to guide scientific research never met since inception and had become defunct; lamented the IMS mindset that had made university- level academic standards for the institute difficult; despaired that as director he had very little say and freedom in running the institute with the PHC being its de-facto director; and, that the civil administration, mostly clerks, in far away Delhi with no experience in scientific matters had complete control over both technical and financial matters reducing the AIIHPH to a mere government department.^[5],[6]

Independent India

Independence appears to have made little difference to the status of medical research as the ‘overwhelming statism’ that had developed during the colonial period persisted and reinforced its control over medical institutes. Foreign agencies and experts engaged in developing the medical programme in India identified two tendencies within the government, which posed a challenge to institutional autonomy. The RF officers, for instance, observed that over a period of time, with a gradual decline in governmental efficiency, there would be a tendency for the bureaucracy to intensify control, with Grant claiming that ‘the Indian mentality was a bureaucratic mentality.’^[10] The post- independent state had continued with the same civil service that had served the colonial state. The other was centralizing tendencies in the government.^[10] Harry Friedgood, professor of Clinical Medicine, University of California in his memorandum to Nehru on medical education and research in India stated that the reason for the unpopularity of health minister Rajkumari Amrita Kaur in the states was not her incompetence but their fear that if she succeeded in ‘centralizing medical educational authority in New Delhi, this will set the pattern and establish a precedent for the further encroachment of Central government upon their inalienable rights… ’^[11] Jawahar Lal Nehru, the first prime minister of India, apparently agreed with this assessment. How the health ministry and the bureaucracy exercised their hold over medical research institutes and AIIMS in particular is described in the discussion that follows.

In 1943 the Government of India constituted the Health Survey and Development Committee also known as the Bhore Committee as a part of its efforts to plan for post-war reconstruction. The committee was to survey existing medical and health services and make recommendations for future planning of medical and healthcare in India. The Report came out in 1946. Among its recommendations were a Medical Research Council for India and an All India Medical Institute.^[12] It recommended a research council modelled on the lines of the British Medical Research Council, ‘unfettered … in the formulation of its research policy, with full powers to hold and disburse moneys allotted to it from public fund, or placed at its disposal by private beneficiaries.’^[12] This was a fairly clear statement on its autonomy with its scope defined. To further reinforce this autonomy, the Bhore Report suggested a Scientific Board with representatives from among prominent medical professionals and scientists of allied sciences. The Government of India after independence acted on this recommendation for a Research Council by transforming and renaming the IRFA into the ICMR retaining certain essential characteristics such as a GB that was heavily dominated by representatives from government-run institutions, nominated by the Ministry of Health and the Director General of Health Services. The ICMR was, in the words of Robert Watson, a RF officer, ‘a sort of holding company for the centre (Central government) to promote graduate training in medical science and medical research.’^[10] In 1959, the health ministry suspended the ICMR's research programme for 1959–60 with the health secretary reprimanding it for the lack of a ‘coherent or well-considered policy’ for ‘the promotion of medical and allied scientific research’.^[12] The Reviewing Committees of 1966 and 1968 appeared to see things differently with the two noting that the ICMR was operating ‘as a subsidiary department of the Ministry of Health unlike its counterparts in spite of the fact that an autonomous function was envisaged throughout’ and that powers of the head of the Council ‘are certainly lacking in the freedom of action in the matter of finances, foreign exchange, customs exemptions and ordinary development programmes because of the constant need for approval.’^[12] The powers of the secretary of the ICMR were also limited requiring approvals and sanctions from different ministries. With ICMR's autonomy so constricted, it is not difficult to imagine the fate of all bacteriology laboratories and medical institutes that came under its purview. For some inexplicable reasons the ICMR was never given the same status as the Council of Scientific and Industrial Research (CSIR) under the Ministry of Science and Technology^[12] under whose aegis around 20 national laboratories and science institutes were established.

Aiims in Parliament

The Bhore Committee recommended the establishment of an All India Medical Institute as a specialized centre for high-quality postgraduate medical education which came into being as AIIMS. As a centre for postgraduate studies it was to be given the powers and functions of a university to provide international standards of medical education, train teachers and develop a research programme. L.R. Allen of the RF which was providing aid and assistance for its establishment, however, sceptically wondered whether the Indian government red tape would allow it to develop into such an institute and hoped its GB, ‘should be free from interference from political forces desiring to gain special advantage’^[13] articulating the same concern that RF officers had expressed during the discussions surrounding the founding of the AIIHPH.

In the Parliament debates on the AIIMS Bill (1956) members expressed concern on the nature and extent of government control over the management and functioning of the institute and what appeared to be an overwhelming representation of government nominees on its GB. Among the MPs who participated in the debates were former members of the Bhore Committee and persons with strong academic experience and credentials. Kaur in turn assured members that the government would exercise minimal control and ensure that AIIMS was endowed with a large measure of autonomy.

The AIIMS Bill provided for 17 members in the GB that included representation for ministries of education and finance; MPs; medical faculties of universities; and representatives of the Indian Science Congress. With three different ministries involved the divergent pulls and pressures on AIIMS become evident (which is discussed later). Both in the Lok Sabha and Rajya Sabha, members participating in the debates proposed amendments, demanding increase in representation for nonofficials, Parliament, university medical faculties, non-medical scientists and a curtailment in the number of government nominees with a change in the government's right and procedure to nominate members to the GB. In the Lok Sabha, Mohanlal Saksena argued that if AIIMS was to be an autonomous institution Parliament would not have much control over it and suggested the need for greater Parliamentary control and representation in the GB adding, ‘It is an Institute of national importance. We realize it, but there is no national approach. There is an anti-national approach.’^[14] Renu Chakravarty suggested that the GB should have more than four representatives of medical faculties from universities ‘because it is necessary that this central institute should become the centre where we shall have all the collective wisdom of all the institutions that are already there in various parts of India— Madras, Calcutta and Bombay where we have very fine institutions which have gained experience as a result of so many of teaching and research. Their experience will be valuable, and therefore, representatives from among those experienced personnel also should be on this institute, so that we shall be able to build and develop on what we have already got.’^[14]

Kaur's reply was to deny any official predominance stating that merely 3 or 4 members of the 17 were officials and that the non-medical scientists, representatives of the Indian Science Congress, medical faculties and MPs could not be termed government officials.^[14] Interestingly, after the Act was passed, a MP who was also a member of the GB introduced an amendment to change the government's right to nominate members to the GB. This attempt was suspected to be directed at clipping Kaur's wings and removing her supporters Drs Jivraj Mehta, A.L. Mudaliar, and C.G. Pandit, director of ICMR from the GB. Kaur reportedly appealed to Nehru to fight off the amendment.^[15] The incident indicates that political adversaries were capable of engaging in tactics to increase their own influence or curb those of their opponents in the management of AIIMS.

The severest criticism came from Joachim Alva particularly about the Selection Committee constituted to appoint professors. The committee, he complained, consisted of very old people above 60 years with no experience of research, clinical work, teaching, or operative work for several years. With no ideas of their own they were unfit to decide the future of the younger generation of medical professionals. The government would appoint a director most probably a retired politician without any teaching or operative work experience who he said would perhaps be a ‘khushama’.^[16]

In the Rajya Sabha, Bhupesh Gupta thought there were too many government nominees in the GB and wanted the nomination to be free of any government interference through wide consultation including medical associations. In his view, the running of the institute in an efficient and democratic manner and minimising bureaucratic or arbitrary interference was most important.^[16] A.R. Wadia, director of the Tata Institute of Social Sciences shared Gupta's misgivings and hoped ‘that the nominations will be exercised not for political reasons but in the pure interests of medical science.’^[16] Jaspat Roy Kapoor believed that as long as the rules governing the management of the Institute were framed by the government, it could not be autonomous.^[16] P.N. Sapru, former member of the Bhore Committee, reminded the House that the committee had been explicit on the Institute's autonomous character. It was not to be run as a government department with all powers ensuring autonomy guaranteed to it, including those pertaining to making rules.^[16] H.C. Dasappa argued that it would be better for the future of the AIIMS if it was free of any ‘red-tapism’ and its autonomous character as a scientific institution assured.^[16]

The most noticeable omission was the absence of representation for the MCI and the exclusion of the AIIMS from its jurisdiction. This attracted much criticism. Sapru highlighted this as a major divergence from the recommendations of the Bhore Report. Kaur's response was that the AIIMS was not a ‘stereotype medical college’ and was kept outside the purview of the MCI control to affirm its independence.^[16] Another explanation offered was that since the MCI did not recognize certain US and Canadian medical qualifications, this would disqualify several prospective faculty members.^[17]

The strongest plea for the institute's autonomy came from Akbar Ali Khan and Professor Radha Kumud Mookerji. Khan expressed concern that the various provisions in the Bill seemed to make the AIIMS a section of the health ministry, which he observed was ‘fundamentally wrong’. Khan reasoned:

If we want to have a research institute, the basic principle, according to me, should be that it should be as far as possible autonomous. You may appoint the best people that you can get and then leave them the liberty; leave them the opportunity to grow and to develop the institution. These institutions develop mostly round the personalities and when you have excellent people who are devoted to research in those cases the Institute will flourish, but if it is made to develop as a section, as a part of the Ministry, howsoever eminent may be the Minister and the staff—it will not work, because officialdom, red tapism, would hamper its growth. The feeling that nobody should interfere in their work and administration should be there, otherwise it's definitely against the best interests of a research institute.^[16]

Mookerji's contention was that AIIMS was planned as a Central university and as a research centre for advancement of knowledge. This entitled it to autonomy so that it could undertake research ‘with a considerable degree of harmony and freedom from interference from outside’. According to him the Tata founded Indian Institute of Science, the National Physical Laboratory and the National Chemical Laboratory (both CSIR institutes) enjoyed a high degree of freedom and were, ‘not at all troubled by any kind of unreasonable interference from outside’.^[16] He wondered why the academic autonomy granted to all institutions working for advancement of learning should be grudged to an ‘institution which contains so much of promise in the sphere of advancement of medical learning’.^[16] To him it was important to ‘leave the institute to develop its own tradition and precedents so that it may work in perfect independence’. He considered parliamentary control interference and an impediment in advancing educational interests. The very nature of the institute's work, he observed, justified grant of autonomy.^[16]

Questions were also raised about the powers given to the Central government to make rules for AIIMS. Kaur argued that Parliament should trust government to treat fairly those in charge of the institute and promote autonomy and elasticity essential to its proper functioning.^[16] She also pleaded with the House to trust the scientist members of the GB who would work ‘whole-heartedly for its growth’ and not make rules and regulations that would ‘in any way cramp their institution’. The government, she said, would make rules on the advice of the GB.^[16]

The Act provided for the President of AIIMS to be also chairperson of the GB. A clause stated that holding the post of president of the institute would not be considered an office of profit.^[16] This would not disqualify the person from being a member of either House of Parliament. Effectively, it paved the way for the minister to be president of the institute and chairperson of the GB. Sapru pointed out that the Bhore Committee had intended the president to be an independent person like the Chief Justice of India or the Speaker of the House and not some departmental officer.^[16] Kaur became both president of the institute and chairperson of the GB. R.S. Morison, an RF official, considered this an unwise decision, making it difficult to ensure autonomy for the institute, which was essential for its proper functioning.^[18] When she ceased to be minister in 1957, she continued to be chairperson of the GB. Apparently, this was done to appease her after her ouster from the ministry, which she claimed was due to the machinations of some of her colleagues. However, these complicated matters further for although she remained the chairperson, her influence was reduced and she appeared to be in constant conflict with the new minister of health, D.P. Karmarkar, who appeared to have little interest in the institute, which had come to be identified with Kaur.^[18] This forced Kaur to regularly approach Nehru, making M.C. Balfour,

RF representative in India, observe, ‘the autonomy of the institute's governing body of which she is president (chairperson) has proved mostly a myth’.^[15] Her holding this office, Morison observed, ‘is not as powerful a position as it should be since virtually all decisions have to be cleared through the ministry of health’.^[19] He added, ‘It would seem as though India is going to have to give a great deal of thought as to how to decentralize its activities in various spheres over the coming decade. Too many decisions are referred up to cabinet level.’^[19] Balfour noted that the internal strife of the AIIMS in which several cabinet ministers were involved, had created uncertainty about the government programme for the AIIMS.^[15]

Kaur had assured Parliament that the future of the institute was in the hands of the director and professors.^[14] She also felt there was no need for anxiety about conflict between the teachers and the GB: ‘Now I see no reason whatsoever why scientific men should quarrel with each other. GB will lay down policies, but internal administration will be the burden of the Director with such staff as is under him.’^[16] In 1959, the faculty at AIIMS recommended that three teaching members be appointed to the academic committee. Since this would require an amendment to the AIIMS Act, L.S. Mudaliar, a member of the AIIMS GB and former member of the Bhore Committee, feared this would open the way for other less desirable changes and action was withheld.^[17] The Rockefeller Foundation's AIIMS Review Committee of 1964 recommended academic control over academic matters.^[17] Once again it was suggested that there should be adequate representation to the academic staff on the GB for effective participation in formulation of academic policy and programmes and the management of the Institute. The committee also recommended liberalization of the financial and administrative control along the lines of the University of Delhi.^[17] This was never followed up, reflecting the clear diversity of views among different arms of the government.

Any hope that AIIMS would have control over appointments was misplaced and all decisions regarding appointments were made in the health ministry with the finance department having the final say on most expenditures. Soon after its establishment, it was not uncommon for the director and the GB to be at loggerheads with the ministries which would often raise objections to their proposals and requests for resources and facilities.^[3] The flimsiness of assurances on its autonomy was further evident when the health secretary informed RF officers Balfour and Allen that the ministry had to be consulted concerning all proposed aid to the AIIMS even as he admitted that it was not improper for them to negotiate directly with the AIIMS management. Balfour noted: ‘Although the AIIMS is an autonomous body which can accept grants from any sources the real fact is that the ministry does control the institute and its governing body in the final analysis.’^[20] At no time did the ministry let go an opportunity to assert its claim to control and run the affairs of the AIIMS.

Concluding Remarks

In India, historically, medical research institutes have been under government control. AIIMS was proposed to be different as provisions of the AIIMS Act and the debates in Parliament show. However, its autonomy has been compromised in different ways. The relationship between academic institutions and the Government in India is iniquitous and often tense. The dependency of institutions on political functionaries and bureaucrats for appointments, tenure and funding is coupled with an excessive intrusion in their everyday functioning in the name of ensuring accountability. Institutional autonomy and professional independence are essential for the effective and efficient functioning of academic institutions and of those working in them. This is as true for medical research institutes. While institutional autonomy may not guarantee individual autonomy the latter is greatly dependent on the former. Andre Beteille, the Indian sociologist who has written extensively on universities in India, points out that any attempt to make scientists, researchers or academics subservient to the state and its political and bureaucratic apparatuses is ‘detrimental not only to their dignity but also undermines the integrity and the quality of their work’^[21] and further contends that autonomy for these institutions is ‘an essential condition for the health and well-being of a democratic society’.^[21]

This is a broad social goal to which medical institutes with other academic bodies can contribute but medical research in India faces more specific difficulties. I draw attention to one of these myriad problems. It has been argued that absence of or limited institutional autonomy with an overwhelming government control creates an oppressive dependence that can be a major impediment to the advancement of medical science in India—an issue that medical professionals and others concerned need to reflect upon.

Acknowledgements

I would like to thank the anonymous reviewers and Mangesh Kulkarni for their useful comments and suggestions.