Balancing Regulation and Autonomy: NCAHP Act and the Psychology Profession in India

The National Commission for Allied and Healthcare Professions (NCAHP) Bill 2020 was passed by the Indian Parliament on 24 March 2021. The President of India gave assent to the bill on 28 March 2021, and the NCAHP Act, 2021, came into force on 25 May 2021, as notified by the Government of India. ¹ The Ministry of Health and Family Welfare notified the rules for implementing the act on 27 May 2021, ² and the interim National Commission was notified on 21 September 2021, as per the act. ³ The regulations for implementing the various provisions in the act were yet to be published as of 15 May 2023.

The NCAHP Act aims to regulate and maintain standards of education and services rendered by allied and healthcare professionals in the country. Several provisions have been incorporated into the act for these purposes, including central and state professional registers, codes of conduct, entrance examinations, curriculum standardization, and so on. ⁴ The act defines two sets of professionals, namely, “healthcare professional” and “allied health professional,” and recognizes 56 professional titles grouped into ten recognized categories.

A healthcare professional is defined in the act as someone who studies, advises, researches, supervises, or provides various health services, including prevention, treatment, rehabilitation, and promotion. An allied health professional is someone who is trained to perform technical and practical tasks to support the diagnosis, treatment, and referral plan recommended by a medical, nursing, or other healthcare professional. ⁴ The definition of healthcare professional is typical of training offered in undergraduate degree programs, and that of allied health professionals is typical of the diploma programs offered in India. ⁵

The regulation of the education and practice of these professions has been a long-standing demand, ⁶ and the current legislation is in line with established international practices. Representatives of some professions covered under the act have welcomed it.^7–9 However, some scholars and professional bodies have pointed out issues that need to be addressed.^10,11 This article analyses the NCAHP Act from the perspective of education and practice of psychology in India and lays out some contentious issues that will have to be addressed during the implementation of the provisions of the act.

The National Commission and Councils

As per the NCAHP Act, the NCAHP is the apex body with a mandate to ensure coordinated and integrated development of education and maintenance of standards of service delivery for the professions covered by the act. ⁴ There would be an advisory council to advise the commission. The commission would constitute national-level professional councils for each recognized category of professions, ensuring representation of all professions covered under the specific category. The act provides little detail about these councils except for their composition.

The National Commission is entrusted with maintaining a central register of allied and healthcare professionals, with separate parts for each recognized category. This register would be a public document. Entry of a person into the register can happen either directly through an application or through a state register. Other duties of the commission include framing policies and standards of governance, regulating codes of conduct and ethics, defining the scope of practice of each profession, setting standards of education and prescribing qualifications, making provision for exit or licensing examinations or postgraduate and doctoral entrance examinations, making provision for the National Teachers Eligibility Test for academicians in each profession, and so on along with other administrative responsibilities.

The act also provides for State Allied and Healthcare Councils to be constituted by each state government. The State Councils are to maintain State Registers of Allied and Healthcare Professionals, with separate parts for each recognized category. Along with other functions and duties similar to those of the National Commission, the State Councils are also to constitute four autonomous boards: undergraduate education, postgraduate education, assessment and rating, and ethics and registration of allied and healthcare professionals. The National Commission, Professional Councils, and State Councils together form the regulatory framework for allied and healthcare professions in the country.

History of the Legislation

To examine the relevance of the NCAHP Act to the profession of psychology, it is prudent to understand the history of the legislation to regulate allied and healthcare professions in India. The initial efforts toward regulation started with the recommendations of the S. D. Sharma Committee. This committee proposed setting up an omnibus council for all paramedical disciplines, with independent professional councils for each profession. ¹² A Paramedical Council Bill, 2001, was proposed. This later led to the introduction of the Paramedical and Physiotherapy Central Councils Bill, 2007, in Parliament. ¹³ This bill focused on the professions of medical laboratory technology, radiology, and physiotherapy. The Parliamentary Standing Committee on Health and Family Welfare considered the bill and provided suggestions to change the title of the bill to “The Allied Health Professions Central Councils Act, 2007” and to provide for elections to posts in the council, among other suggestions. ¹² The bill lapsed.

In 2011, the National Commission for Human Resources for Health Bill 2011 was introduced, which sought to regulate all health professions, including registered medical practitioners. ¹⁴ This bill was rejected because of opposition from professional bodies to the proposed unitary structure. ¹⁵ This was followed by a study commissioned by the government, which recommended several measures for the standardization of the allied health sector in the country. Though the report mentioned “Psychology and mental health counseling” as a potential area for starting courses, the overall focus and discussion on psychology as a stream were minimal. Most statistics did not include professions such as counselors and only covered psychologists engaged in rehabilitation, who were already regulated by the Rehabilitation Council of India. The report proposed certificate, diploma, and degree courses, not post-graduation as is the practice in psychology, as standard qualifications for allied health professionals. ¹⁶

Based on this report, first a National Board for Allied Health Sciences was proposed in 2014, ¹⁷ and later the Allied and Healthcare Professional’s Central Council Bill 2015 ¹⁸ was drafted. The draft bill did not mention “psychologist” as a profession but included “Integrated Behavioral Health Counselors, Palliative counsellors, etc.” as an allied health profession under the category of primary care and community services. This bill was redrafted multiple times and later introduced in the Rajya Sabha as the Allied and Healthcare Professions Bill, 2018. ¹⁹ The bill was referred to the department-related Parliamentary Standing Committee on Health and Family Welfare for examination and report. The committee consulted various stakeholders and submitted its report in January 2020. ¹⁵ On 15 September 2020, this bill was withdrawn, and a new bill incorporating the suggestions of the committee, the NCAHP Bill, 2020, was introduced in the Rajya Sabha. ²⁰ This bill, upon being passed by the Parliament and getting the assent of the President, became the NCAHP Act, 2021.

The NCAHP Act was a major step toward standardizing the allied healthcare professions in India. There has been a long-standing demand for such a law.^21–23 However, some issues specific to the training and practice of psychology need to be discussed and addressed. Some of these issues are related to the evolution of this law, which was initially meant for professions such as physiotherapy, optometry, and radiology. These professions are practiced in contexts fundamentally different from those of psychology. Some issues are related to existing laws, and others are related to international practices, and conventions.

The Teaching of Psychology in India: Present Scenario

Psychology is mainly taught as an academic discipline at the undergraduate and postgraduate levels in colleges and university departments in India. Psychology is also taught at the 10+2 level as an optional stream. The basic eligibility requirement for admission to the undergraduate course is completing 10+2 or an equivalent examination. Eligibility criteria for admission to the postgraduate level vary across universities. Some universities require an undergraduate degree in psychology as a necessary qualification. Other universities allow anyone with an undergraduate degree to apply for admission to a postgraduate degree. Common entrance examinations, such as the Central University Entrance Test for Postgraduate (CUET PG) programs conducted by the National Testing Agency (NTA), allow undergraduates in any discipline to appear for the entrance test. There is considerable variation in syllabi and course structure across universities as well. ^24,25 The variation in curricula can help higher education in psychology be diverse and inclusive and present an opportunity for innovation and experimentation in the teaching-learning process. However, for professional and clinical training in psychology, this variation can pose the risk of inconsistency in the quality of education and may lead to a lack of standardization.

Nomenclature, Definitions, and Coding

The NCAHP Act has listed psychologists under a heterogeneous category of “community care, behavioral health sciences, and other professionals.” This category also includes 13 other professions, such as ecologists, social workers, and health educators. The professional titles related to psychology, such as behavioral analyst, disease counselor, and integrated behavior health counselor included in the schedule, are neither taught nor practiced widely in the country.

Many stakeholders opposed the usage of the term “behavioral health” instead of “mental health” during the discussion on the 2018 bill. ¹⁵ The ministry had claimed without providing any evidence that there was evidence for refraining from using the term “mental” to indicate behavior-related health issues since it was considered derogatory and disrespectful to patients. ¹⁵ This position conflicts with all other legislations and programs of the government, including the Mental Health Care Act (MHCA) 2017.

Besides, in 2018, the central government approved the establishment of the National Institute of Mental Health Rehabilitation (NIMHR) in Sehore, Madhya Pradesh, as a central autonomous institution. All documentation and communication related to this institution use the term mental health, not behavioral health. The switch from mental health to behavioral health is limited to the NCAHP Act alone, without any supporting evidence or rationale. A scenario where only a handful of documents mention behavioral health and only a few professions are labeled as behavioral health professions while the majority of systems follow the term mental health may create practical and procedural issues.

Mental health is an important component of sustainable development. ²⁶ From this perspective, it is imperative that standards are established for the nomenclature of professions and that national standards conform with international standards. Hence, the change from mental health to behavioral health is questionable, also because the nomenclature conflicts with all other existing legislations and regulations. It is to be noted that bringing homogeneity in regulations and practices to achieve global mobility for psychologists has been a long-standing demand, and steps are being taken at different levels to achieve such homogeneity.^27,28 A step in the opposite direction could prove detrimental to the profession’s future within and outside the country.

The switch from mental health to behavioral health could also create a situation where behavioral health professionals may not be recognized as mental health professionals as per the provisions of MHCA, 2017.^11,29 Ambiguities regarding the treatment of common mental disorders not covered by the MHCA, 2017, could also arise, leading to practical and policy issues. The definition of mental illness as per the MHCA, 2017, is more suitable for severe disorders than common mental disorders. Also, MHCA, 2017, does not mention behavioral health professionals. ¹¹

The NCAHP Act also leads to a situation in which clinical psychology continues to be regulated and governed by the Ministry of Social Justice and Empowerment through the Rehabilitation Council of India ³⁰ , while all other branches of psychology will be governed by the Ministry of Health and Family Welfare through the new Professional Council to be established. ³¹ This could lead to a lack of coordination and integration between different branches of psychology, which may negatively impact the quality of training and mental health services provided in the country.

Another issue with the nomenclature of professions is that commonly used professional titles such as counseling psy-chologist, adolescent counselor, school psychologist, child psychologist, consultant psychologist, and so on, are not included in the schedule of the act.

It was claimed by the Ministry of Health and Family Welfare that the nomenclature of professions in the act was decided as per the International Standards for Classification of Occupations (ISCO) of the International Labour Organization (ILO). However, there are some discrepancies between the original ISCO codes and the NCAHP Act. In 2019, the World Health Organization released the international classification of health workers, mapping health professions based on the ISCO. ³² The classification of health workers proposed in this document has not been incorporated into the NCAHP Act, at least in the case of psychologists. The original ISCO code of 2634 for psychologists lists educational psychologists, organizational psychologists, psychotherapists, and sports psychologists as specific examples of occupations, apart from clinical psychologists. None of these are mentioned in the schedule of the NCAHP Act. Professions originally included under the ISCO code 2635, such as addictions counselor, family counselor, marriage counselor, and so on, are not mentioned in the schedule, whereas professions such as behavioral analyst and health educator, not mentioned in the ISCO, are included. It is also to be noted that India’s National Classification of Occupations, 2015 ³³ , which is aligned to the ISCO 08, includes titles such as social psychologist, industrial-organizational psychologist, counseling psychologist, and educational psychologist, but these titles are not listed in the NCAHP Act. These discrepancies could be addressed while the detailed regulations for the act are framed.

Structure of Courses and Training Requirements

The qualification prescribed for professional practice as an allied health professionals in the NCAHP Act is a diploma or degree of two to four years (2,000 h). For healthcare professionals, it is a degree of 3–6 years (3,600 h). In the act, postgraduate education is construed as an advanced qualification. This is evident from the provision of exit or licensing examinations for professional practice or entrance into postgraduate level after an undergraduate degree. ⁴ Though this course structure could apply to most allied and healthcare professions in India, this is a departure from the existing system for psychology. As per international practices too, the common requirement to register and practice as a psychologist involves an equivalent of a master’s degree or a higher qualification such as a doctorate.^34–37 This discrepancy with international practices may lead to the dilution of standards and make international mobility difficult for professionals.

The rules notified for implementation of the act stipulate that new allied and healthcare institutions should have an attached hospital. ² Though having a practicum-intensive curriculum is beneficial for students of Psychology, ³⁸ it is unclear as to how university departments and colleges offering undergraduate degrees in clinical branch of psychology could achieve this, especially since practicing as a professional psychologist continues to be the most sought after career plan for students of psychology. ³⁹ Academic institutions can partner with clinical institutions to meet the requirement for clinical facilities. The Rehabilitation Council of India already has guidelines for liaising with clinical institutions to train MPhil Clinical Psychology trainees. ⁴⁰ A provision for institutional training, either through an attached hospital or through such partnerships, could bring more practical exposure to students, which is necessary for professional training.

Regulation, Autonomy, and Representation

The internationally accepted practice for regulating practice in psychology is through a joint effort from the government and independent professional bodies, with professional bodies in developed countries having more autonomy. ⁴¹ While professional bodies focus on setting standards for education, training, and ethical conduct, regulatory bodies established by governments oversee licensing, legal frameworks, and the enforcement of standards.^42,43 In India, too, better professionalization and an independent body for regulating psychology have been long-standing demands.^15,44,45 The proposed regulatory framework in the NCAHP Act brings all these functions under the ambit of the National Commission and Professional Council, which are nominated by the government, leaving little room for self-regulation and autonomy.

The proposed structure of the national commission and professional councils may not guarantee adequate representation of psychologists. Psychology is included in the total of 14 professions listed under the category of behavioral health sciences and other professionals. These professions fall under at least four groups of professionals. The corresponding professional council will have a president who will be a member of the National Commission, and the presidency will be rotated biennially among the professions. Hence the apprehension within the psychology community that there is no guarantee that psychology will be permanently represented in the National Commission, unlike professions such as physiotherapy or occupational therapy that will have permanent representation. ³¹

Lack of autonomy for the profession is another likely fallout of the act in its present form. With the National Commission and councils being mostly nominated bodies, there could be considerable state control and centralization of power and decision-making. This could hamper self-regulation and restrict autonomy, both crucial elements for the growth of a profession. ⁴⁶ Remedial mechanisms available in cases of conflicts between the National Commission or state councils and members of the profession are limited. There is a bar on the jurisdiction of civil courts on matters relating to removing someone’s name or refusing to enter someone’s name in the central or state registers of professionals. ⁴

There is also confusion regarding the rights of psychologists to practice independently. The act does not state which professions under the category of “behavioral health sciences and other professionals” are healthcare professionals and which are allied health professionals. The definitions of the two types of professionals in the act suggest that only healthcare professionals could practice independently. In the case of professionals such as physiotherapists and occupational therapists, the act explicitly states that they can practice independently. There is no mention of the right of psychologists to practice independently. The regulations, when published, need to address these issues.

Discussion and Conclusion

The NCAHP Act could benefit the training and practice of psychology by addressing some issues. The issues of compatibility, mobility, and possible legal hurdles related to nomenclature arising from the switch to “behavioral health” from “mental health” in the official language need to be addressed properly. Addressing these issues is necessary for standardizing the task-shifting efforts, which may be necessary ⁴⁷ to strengthen the community mental health movement to address the large mental health treatment gap that exists in India. ⁴⁸ The importance and need for task shifting, as acknowledged in the National Mental Health Policy (NMHP), ⁴⁹ do not seem to have been reflected in the provisions of the NCAHP Act. ⁴⁸ Discrepancies with the ISCO of the International Labour Organization must also be addressed to ensure international standards and mobility for professionals.

The proposed structure of certificate, diploma, and degree courses as standard qualifications as per the act marks a departure from the existing system. This would demand careful consideration to keep up with international practices and standards. A restructuring of psychology teaching and training may be needed, with clearer demarcations for psychology as a professional and academic stream of learning and increased practical training for those in the professional stream. It needs to be ensured that no dilution of existing standards happens through the reforms.

The proposed regulatory framework for psychology raises concerns regarding the autonomy and self-regulation of the profession, which are crucial for its growth and development. With regulation largely under government control, there is a risk of state control and centralization of power. Additionally, the lack of clarity regarding the right of psychologists to practice independently may create confusion and hinder the profession’s growth. The regulations must address these issues and provide adequate representation for psychologists in the National Commission and professional councils. A collaborative effort between the government and independent professional bodies, with professional bodies having more autonomy and internal efforts toward professionalisation, ⁴⁴ may be a better approach.

By addressing the concerns related to nomenclature, training standards, representation, and autonomy in psychology, the NCAHP Act could be leveraged as a catalyst for the reorganization of the profession of psychology in India’s journey toward sustainable development goals.