DOCTORS FOR THE VILLAGES-STUDY OF RURAL INTERNSHIP IN 7 MEDICAL COLLEGES
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© THE JOHNS HOPKINS UNIVERSITY, 1976
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Preface
Like many other countries, India has been caught in the health
manpower planning crisis, popularly known as the “Qualitative/
Quantitative dilemma.” The State policy is one of distribution of
health services widely all over the country, across social lines and
irrespective of ability to pay. Doctors have always been visible
symbols of health care but they simply won’t go to the villages by
sermons. We need to know why they won’t go; we need to know what
they should be doing out there once they get there. In effect, we need
to know what are the most effective ways of health care delivery within
the resource constraints, the reality of spatial distribution of the
population and their socio-cultural background. This book deals with
these issues.
This is a study of the attitude of interns towards rural health
services and towards their training in rural health care. Data were
collected over three full years from a total of 1480 interns coming
from seven medical colleges in India. The institutions selected varied
in size, student composition, rural and urban backgrounds of students,
etc., and taken together can be said to be fairly representative of the
medical colleges of India. The motive force for the study is that on
the basis of the information obtained, it should be possible to identify
the changes that will be needed to attract young doctors and improve
services in rural India. The result is a fascinating study with profound
practical implications.
vIt .should come as no great surprise to those who are conversant
with medical education that the interns attached the highest prestige
to surgery while social and preventive medicine and public health
ranked very low. Likewise, surgery, paediatrics, general practice and
v
vi
Preface
internal medicine were ranked very high in personal preference while
public health was placed at the bottom of the preference scale.
However, the most important and, to my mind the most optimistic
finding was that doctors would go to the villages, if opportunities
for service were provided for them, if living conditions and professional
standards were improved. Professional standards were more important
than living conditions and personal factors. Inadequate provision of
drugs, supplies and equipment, lack of opportunity for professional
advancement and postgraduate education, poor access to libraries and
reference materials were identified by the interns as the most important
deterrents for effective rural work. Interestingly, not enough pay was
not a high ranking factor. Interns with rural backgrounds and from
lower socio-economic strata expressed greater interest in rural health
centre work than the others.
The book goes beyond the analysis of the interns’ responses;
it discusses a number of related issues, equally important, in the
context of rural health—the need for role definitions within the
health team and for new relationships between doctors and auxiliaries,
the irrelevance of medical education to rural health work, the value
system within society favouring specialists, the over-simplification of
rural work, the primacy of curative care, the vacuum between the
health centre and the village home and the need for substantial
delegation of clinical and preventive routines to a supporting category
of paramedical professionals and auxiliaries.
The last chapter gives the findings of the study and matches
them with a set of recommendations for corrective action that should
provide a rational basis for a restructuring of medical education and
indeed of the entire health manpower profile. Dr. Carl Taylor and
his coworkers provide hope where confusion and despair reign.
V. Ramalingaswami
M.D., D.Sc., F.R.C.P.
All-Jndia Institute of
Medical Sciences,
New Delhi
Introduction
Providing primary care to rural areas is the greatest unmet challenge
for health systems in most developing countries. The obvious neglect
is not only because the problems are difficult, but also because there
are no ready solutions. Innovative and realistic field research that
takes into account both the existing situations and the potential
for improvement, provides the best hope for progress. The research
reported in this volume focusses on the potential for utilization of
physician manpower in rural areas, the conditions under which
physicians might agree to work in villages, and the structural and
organizational changes needed to improve rural health care. This
research was conducted in rural India as a collaborative international
effort. We believe that the lessons learned have wide applicability in
all countries.
It is easy to forget the truism that health care depends upon
the quality of health personnel as much as on their numbers. But
we need to redefine quality in terms of what is best for the poor and
deprived rather than continuing to use the customary norms of what
is the best care possible for the elite. In most of the world, the number
and distribution of doctors is used as the principal indicator of access
to health care and its quality. Research on health care delivery
(Zola 1963; Roemer 1959; Weinermann 1966; Anderson 1963),
however, suggests that the organization of the whole health care
system and the distribution of all health personnel are more significant.
It is increasingly apparent that relationships among all members of
the health team require major changes. An appropriate place to start
seems to be analysis of the doctor’s role in the health care team and
their preparation for such service.
vii
viii
Introduction
A major continuing complaint is that doctors do not and will
not respond to village needs. Politicians tend to blame doctors for
inadequate medical services in rural areas. Leaders in health services
and in medical education have also tended to join this widespread
criticism of the urban orientation of young medical graduates, but
only after they were safely beyond any prospect of being expected to
work in villages themselves. The shallowness of such criticism is indi
cated by the fact that if doctors were to respond suddenly to the
exhortations and were to volunteer in large numbers for village service,
there would not be sufficient money in health services budgets to
support them or to provide for facilities and auxiliary personnel to
make their work effective.
A continuing fallacy is the notion that large numbers of doctors
represent some sort of ultimate solution to rural health problems. In
fact, the widespread commitment to the affluent country pattern of
trying to have physicians provide all types of medical care is probably
the greatest current obstacle to effective health care for village people.
An entirely new system is needed in which the doctor performs
selected functions as a member of the primary health care team but
most of the more routine work is delegated to others. Only then will
the quantitative problems of coverage be resolved at a cost that is
feasible and at an acceptable level of efficiency to provide good
quality care. Even affluent countries are moving rapidly to the use
of nurse practitioners and physician’s assistants, because an increasing
body of research shows that such a redistribution of functions
improved health.
Since independence, India has been moving progressively toward
developing an autonomous system of health care suited to her own
needs. Through the 1950’s, the conviction grew-that it was not enough
just to expand hospital based urban medical care, which had been
started under British rule, supplemented by private practitioners
practicing on a fee for service basis. A new approach with a distinct
rural orientation had to be developed specifically for India’s needs. The
first emphasis, helped greatly by the personal involvement of the then
Health Minister, Rajkumari Amrit Kaur, was to try to reorient doctors
by changing the content of medical education. Departments of Social
and Preventive Medicine were assigned responsibility for organizing
Introduction
community teaching through rural health centres. The culmination of
this experience was to be the two-to-three months rural internship.
By 1959, it seemed that this educational effort was having a
negative effect on the attitudes of young medical graduates. Efforts
to improve the rural internship experience were seriously handicapped
by the ridicule of many medical college teachers. It was in this
environment that Dr. D.P. Karmarkar, the Minister of Health, asked
that this research be started to define the problems of orienting doctors
for rural service and to search for innovative and truly Indian solutions.
Much of this long term field research was carried out during the
period when Dr. Shushila Nayar was Minister of Health and benefited
greatly from her advice and interest. A succession of Health Ministers,
Secretaries, and other secretariat officials, Directors General of Health
and directorate officials have been deeply involved and have provided
continuing support. Because of the long duration of this research,
many people have contributed greatly and acknowledgement can be
made to only a few who helped most substantively during the field
work in the 1960’s. Some of these are:
Mr. B. P. Patel
Dr. K. N. Rao
Dr. N. Jungalwala
Dr. T. R. Tewari
Dr. P. R. Dutt
Dr. Deepak Bhatia
Dr. J. B. Shrivastav
Dr. G. P. SenGupta
Mr. D. N. Chaudhuri
Miss A. Cherian
Since the official channel of liaison for this research was through
the Indian Council of Medical Research, we also gratefully acknowledge
the contributions of the ICMR Directors General and members of their
staff including:
Dr. C. G. Pandit
Dr. P. S. Venkatachalam
Col. B. L. Taneja
Dr. P. N. Wahi
The research particularly benefited from the continuing personal
participation of Col. Amir Chand, who represented the Indian Medical
Council and Indian Medical Association, and of Dr. Hugh Leavell of
the Ford Foundation.
The conceptualization, design and analysis of the research
depended largely on the help provided by social science and statistical
consultants. Special acknowledgement is made of the contributions
Introduction
of the following:
Dr. M. S. Gore
Dr. George Litwin
Dr. Y. B. Damle
Dr. Lyle Saunders
Dr. Edwin Harper
Dr. Cora Debois
Dr. C. R. Rao
Dr. J. Roy
Dr. David McClelland
Dr. David Winter
Since a wide geographic distribution of colleges was essential, the
research was conducted in the states of Delhi, Kerala, Maharashtra,
Punjab, Tamilnadu and Uttar Pradesh. The Secretaries and Directors
of Health in these states, with their staffs, provided cordial local
relationships and support. They did the research project the great
honor of rapidly implementing many of the findings. Some whose
contributions are specially acknowledged are:
Dr. P.M. Bhandarkar, Surgeon General, Maharashtra Government
Dr. P.D. Bhave, Director Public Health, Maharashtra Government
Dr. I. Joseph, Director, Public Health School, Trivandrum
Dr. V. Hariharan, Assistant Director of Public Health, Madras Government
Dr. K. Moti Singh, Director of Health Services, Punjab Government
Dr. Harbans Dhillon, Assistant Director for MCH, Punjab Government
Dr. Harinarain S. Grewal, Assistant Director, Punjab Government
The project really belongs to the large group of Indian medical
educators who participated. Most important were the deans, professors
and health centre directors of the seven cooperating medical colleges:
Seth G.S. Medical College, Bombay
Dr. S. Joglekar, Dean
Dr. D.N. Pai, Professor, Social and Preventive Medicine
Dr. C. Sabnis, Medical Officer, Health Unit, Palghar
All India Institute of Medical Sciences, New Delhi
Dr. B.B. Dikshit, Director
Dr. K.L. Wig, Director
Dr. V. Ramalingaswami, Director
Col. T.D. Chablani, Professor, Social and Preventive Medicine
Dr. Y.L. Vasudeva, Associate Professor.in charge of rural internship
Dr. J.R. Bhatia, Associate Professor in charge of rural internship
Dr. L. Allen, Visiting Professor, Social arid Preventive Medicine
xi
Introduction
King George Medical College, Lucknow
Dr. B.G. Prasad, Professor, Social and Preventive Medicine
Dr. S.C. Bagchi, Professor, Social and Preventive Medicine
Dr. K.K. Mathur, in charge of rural internship
Christian Medical College, Ludhiana
Dr. Kenneth Scott, Director
Dr. G.W. Constable, Principal
Dr. B.K. Jerath, Chairman, Social and Preventive Medicine
Dr. Helen Gideon, Professor, Social and Preventive Medicine
Dr. B.P. Malvea, Medical Officer in Charge, Bhagwant Memorial Hospital
Medical College, Nagpur
Dr. P.L. Powar, Dean
Dr. D.K. Ramadwar, Professor, Social and Preventive Medicine
Dr. N.D. Palkar, Medical Officer, Health Unit, Saoner
Dr. K.C. Jain, Medical Officer, Health Unit, Saoner
Medical College, Trivandrum
Dr. M. Thangavelu, Principal
Dr. K.P. Joseph, Professor, Social and Preventive Medicine
Dr. Chitra Gopalan, Associate Professor, Social and Preventive Medicine
Dr. Aysha Guhraj, Associate Professor, Social and Preventive Medicine
Dr. A. Haynes, Visiting Professor, Social and Preventive Medicine
Christian Medical College, Vellore
Dr. John S. Carman, Director
Dr. K.G. Koshi, Vice-Principal
Dr. V. Benjamin, Professor, Social and Preventive Medicine
Mr. P.B.S. Sundar Rao, Statistician
Finally, we thank all those who participated directly in the field
research, the members of our staff who served so faithfully under
extreme constraints in their personal living over the many years of
effort that were necessary to gather and process these data.
Then, there is the reality that those who contributed most are
the 1,480 interns who entered enthusiastically into this effort to
improve the preparation of those who would follow them in learning
xii
Introduction
about and living among tire wonderful village people from Punjab
to Kerala.
This research effort has been a truly collaborative
adventure. It is our hope that findings such as these will contribute
to the greater adventure of developing an expanded and more effective
system of care for village India.
Carl E. Taylor
Joseph D. Alter
Prakash L. Grover
S. Prakash Sangal
Sunny Andrews
Harbans S. Takulia
December, 1975
Contents
Preface
u
Introduction
Wf
Chapter 1
The Need for Research in Rural Health
1
Chapter 2
Methodology of the Research Project
16
Chapter 3
The Seven Cooperating Medical Colleges
30
Chapter 4
Social and Demographic Characteristics
of Interns
44
Chap ter 5
Career Choice
53
Chapter 6
Attitudes of Interns to Primary Health
Centres and Villagers
69
Chapter 7
Medical Education and Rural Internships
97
Chapters
The Need for a New Rural Health System
117
Chapter9
A New Pattern of Rural Medical
Education
135
Chapter 10
Findings and Recommendations of
The Fourth Narangwal Conference
147
Bibliography
163
Appendix
170
1
The Need for Research
in R ural Health
Improving the health of village people is fundamental to India’s
development objectives. It is good economics because of the clear re- J
lationship between health and productivity, especially where agriculture}
dominates economic production. It is good politics because most}
voters are rural people and better health care is a primary demand. V
It is also becoming increasingly evident that it makes good sense demographically because of the synergistic potential of integrating health
and family planning services. Above all, health care for the rural poor J
is recognized as a basic right. Social justice demands that they be
provided access to the basic services which are now feasible.
Early efforts in rural health in India sought mostly to control
epidemic diseases, especially through smallpox vaccination. Several
isolated village projects were started in the early 1920’s, such as
Tagore’s innovative combination of health and rural development at
Sriniketan and Shantiniketan. Then, starting around 1930, seven ■
model rural health units were established in different states with the
assistance of the Rockefeller Foundation. Gandhiji’s efforts to define
simple but effective measures for rural development at Sevagram
increased public awareness of the needs of village people. Various
mission groups conducted outstanding pilot programmes, such as
India Village Service organized by the Wisers (1963). Programmes
to bring good health care to the villages expanded rapidly after
independence in 1947.
The pattern for long-range development was set in 1946 by the
Bhore Committee Report, which provided a revolutionary and closely
reasoned blueprint for the reorganization of health services (Bhore
1946). Curative and preventive services were to be integrated and
2
Doctors for the Villages
provided through an ambitious hospital-based and regionalized system
of primary and secondary health centres. With the first five-year plan
in 1952, health became part of the national community development
program. The negligible number of primary health centres (PH,C’s)
then existing grew to some 725 in 1955, and is more than 5,000 now.
The original goal of one centre for every community development
block of about 80,000 people has almost been reached. Typically, a
health centre is, staffed with a team of about forty paramedical and
auxiliary personnel under the leadership of one or two doctors. In
most states, however, attempts to attract doctors to the rural areas
continue to meet with limited success.
Because of the obvious need for more doctors, opportunities in
medical education were increased tremendously after independence.
Twenty-two medical colleges existed then; today there are over one
hundred (Institute of Applied Manpower Research 1967).
Some
10,000 medical students graduate each year with the M.B.B.S. degree.
In some states, production of doctors exceeds urban demand, and
Si when they have nowhere else to go they reluctantly accept health
centre positions as a necessary step in a career of government service.
Many try to emigrate.
The effort to increase the production of doctors, great as it is,
will not by itself meet the projected demands of India’s rapidly growing
population. Sixty-seven percent of India’s doctors live and work in the
urban areas, while eighty percent of the population continues to live in
* rural areas. For the total population, there is one qualified doctor for
each 5600 people, but for rural areas the ratio drops to one in every
28,500 (IMA 1973). It is increasingly evident that just raising doctor
production, even with extensive redistribution, will not meet India’s I
health manpower needs. Besides, the government cannot provide
salaries for the great increase in numbers needed to achieve a doctor/
patient ratio which realistically attempts to meet the expectation that
doctors will provide all medical care.
Simple calculations of numbers and distribution of medical
professionals, then, do not define the real problem. Innovative think
ing is needed on the more basic issues of reorganizing role definitions
within the health team, with special attention to new relationships
between doctors and auxiliaries (Fendall 1972; Josiah Macy, Jr.
Foundation 1973). Indian medical education is following a worldwide
trend toward specialization. Professional role rigidities are imposed in
exclusive orientation toward teaching hospitals. This severely handi
The Need for Research in Rural Health
3
caps the young doctor in adjusting to the normal conditions of patient
care, especially in rural health centres (King 1968; Bryant 1969).
The fact that the doctor’s professional training does not prepare
him for routine health services and community health care is only the
beginning of the problem. More lasting psychological obstacles
develop because it is evident that society gives the highest professional
rewards to clinical specialists working in hospitals (DeCraemer and
Fox 1968). Values are transmitted to medical students by their
adopting teachers as role models (Gregg 1957; Vemey 1957).
Professional standards of behavior are learned from what students
actually see and do in their training, and not from what they are told
(Merton et al 1957; Becker et al 1961). Largely because the
romanticized hospital role epitomized by medical teachers distorts
expectations, even high level achievement in other health activities
tends not to bring much career satisfaction. Despite all the speeches of
national leaders and medical educators about the needs of village people
medical colleges continue to provide no respected role models to
encourage doctors to work in primary health centres. No primary
health centre doctor in India has been given a major award or other
national recognition.
The first Health Survey and Planning Committee (Bhore 1946)
urged the development of a wholly new orientation: “India being
more than 80 percent rural, the training given to a doctor should enable
him to carry on his work among the vast masses in the villages.”
Inculcating this new orientation was thought to be an easy matter
because the health problems of villages were thought to be simple.
Idealistic motivations led to over-optimistic expectations. During the
first two five-year plans, officials and villagers shared a surge of hope
as their enthusiasm for change became the underlying force in the
phenomenally rapid expansion of community development program
mes. The ideas underlying the health centre part of the movement
were so logical, persuasive and rational that it was naively assumed that
implementation would be rapid and easy. These efforts must not be
decried; without such hope and enthusiasm, the tremendous progress
of the past twenty years would not have been possible. On the other
hand, hopes and ideals are not surrogates of reality.
The rapid expansion of rural health services left the primary ,
health centre doctor and his staff with an impossible burden of
responsibility. The doctor was expected to translate hopes into
realities, and it was he who found that the process was not simple.
4
Doctors for the Villages
The manuals for health centre work which were developed as guides for
tire PHC doctor illustrate how unrealistic the expectations were (Dutt
1963; Takulia et al 1967). No superman could have coped with the
list of twenty or more major responsibilities. The doctor was expected
to be all tilings to all people in the community development block.
The result was that most PHC doctors did not even try; they merely
dropped into the pattern of doing that with which they felt most
comfortable—clinical care at a very simple level for those able to come
from villages within a radius of a mile or so (McPhail 1963; Reinke et
al 1974). There were enough patients to keep them busy.
In an earlier volume in this series (Takulia et al 1967), we
defined twelve basic elements required to make the health centre
concept work:
1.
A Regionalized Framework. Health centres must be organ
ized in regional systems around the base hospitals and medical centres.
2. Responsibility for Defined Geographic and Population Units.
A health centre should have responsibility for a well-defined population
and geographic unit conforming, in general, to an established political
or administrative unit.
3. Comprehensive Care. A full range of preventive and curative
services must be integrated with appropriate referral of problems from
auxiliaries to general practitioners and specialists. Services should be
provided at the place and time most convenient to the patient.
4. The Community as the "Patient. ” The focus of professional
attention should shift from individuals to the whole population as a
unit, the presently healthy as well as the sick.
5. The Family as the Basic Community Unit. The fundamental
health care unit should be the family. Personal preventive measures
and clinical care require family support, and changes in health practices
are often at the family level.
6. Community Participation. Community participation is essenttial and can be achieved only by careful delegation of selected areas of
control.
The Need for Research in Rural Health
5
7. Method of Payment for Health Services. All members of the
community, however defined, must have access to the services. The
magnitude of the total cost makes comprehensive services expensive,
even for affluent governments. It may be desirable, therefore, to have
j some mechanism enabling the non-indigent to contribute to the cost
of their care. Direct local support can most readily be mobilized for
drugs and for some preventive services, such as a safe water supply,
which are recognized to be primarily a convenience rather than a
specific health measure. If members of the community control funds
they consider to be their own, there is less likelihood of mis
appropriation.
8. Controls Within Regional Organization. Centralized control
within the regional organization must be balanced with local commun
ity control and initiative. In distributing functions, central control
may be exercised in setting policy and standards and influencing the
flow of funds, while communities retain flexibility in setting local
priorities, thus increasing their participation in implementation.
9. Team Orientation. The staff of the health centre should
be trained to function as a team. To improve utilization of the skills
and training of each person, an analysis of functions can provide a
basis for more rational job allocations.
10. The Role of the Health Centre Doctor. As the generally
accepted leader of the health centre team, the doctor should perform
personally only those tasks which cannot be delegated safely to other
personnel. His most important jobs are staff supervision and continuing
education. The medical care load must be distributed to maintain an
appropriate balance with preventive functions. The doctor should treat
only referred cases.
11. The Role of Other Health Centre Personnel. Nurses and
health auxiliaries should assume major responsibility for both pre
ventive and curative work with clearly delineated role definitions
and standards of performance. A critical unmet need is the develop
ment of clinical and preventive routines with standing orders and
manuals. While most standard procedures can be delegated down,
there should also be routine provisions for referral to professionals
of those individual or community problems requiring special judge
6
Doctors for the Villages
ment or technical skills.
12. New Educational Preparation. A new approach to commun
ity-side teaching is needed that will be as revolutionary as Osier’s
introduction of bedside teaching.
Practical learning from field
experience will require a well organized system of community care, just
as a teaching hospital requires a supporting framework of diagnostic
and care services within which a medical student can learn to function
as a doctor.
Around tire world, the increasing priority attached to preventive
and social medicine has been paralleled by growing frustration arising
from difficulties in implementing effective teaching programmes.
The First World Conference on Medical Education in London placed
great emphasis on the place of preventive and social medicine in the
undergraduate medical curriculum (1954). It was generally agreed
that “students should be trained in social medicine in one way or
another throughout the duration of their studies, and that particular
attention should be paid to the practical work of medical students in
institutions, in families, and in field work.” Separate departments of
preventive and social medicine were considered necessary to develop
and manage extramural programmes.
The steady evolution of the new academic discipline of com
munity medicine has been worldwide (Van Zile Hyde 1966; Lathem
and Newbery 1970; Bowers 1970). It was emphasized by a number
of participants at the Second World Conference on Medical Education
in Chicago (1961), and was a major theme of the Third World
Conference in New Delhi (1966 and 1968). A fascinating variety of
programmes in community medicine in the United States and Europe
show considerable ingenuity in planning (Snoke and Weinerman
1965; Reader et al 1967), but the problems in implementation have
continued.
Medical educators in India were in the forefront of the growing
international concern (IAAME 1973; Taylor 1956; Rao 1973). In
1952, some medical colleges responded to the emerging challenge of
preparing doctors for rural work by establishing departments of social
and preventive medicine in place of the earlier departments of hygiene.
The first such departments, at Ludhiana and Trivandrum, developed
the pattern of using rural health centres as teaching laboratories
(Tampi 1954; Taylor 1955). Students were exposed to the basic
The Need for Research in Rural Health
7
sciences of community diagnosis and care—i.e., biostatistics, epidemi
ology, and the social sciences. They were encouraged to go beyond
clinical understanding to form an appreciation of patients as whole
persons, influenced by multiple environmental factors. They were also
taught to provide simplified care appropriate for rural conditions. It
was recognized that special orientation and skills were necessary to
care for whole communities.
Building on course work in preclinical years, students underwent a
rural internship of two to three months as part of the rotating intern
ship year. By living and working under rural conditions and with
village people, the young physicians were expected to being to under
stand rural health problems under conditions where they could profit
frorrr' professional and personal support. While this field experience
was designed to provide practical learning of both preventive and
curative measures, it tended to be observational rather than experi
ential.
The emphasis on practical field training gained impetus in India
through a series of conferences and meetings following the 1955
Medical Education Conference in New Delhi (GOI 1959). The Indian
Medical Council formally recommended a compulsory three-month
rural (or urban) field internship. Increasing numbers of medical
colleges began community programmes (Haynes et al 1966; Koshi
1966; Chablani 1968).
In 1959, one of us made a general survey of the teaching of social
and preventive medicine in India to evaluate the progress since the
1955 All India Conference on Medical Education. Of the approximate
ly seventy medical colleges in India at that time, about half had some
form of rural internship.
The survey showed that the progress in developing community
teaching programmes for undergraduates was somewhat encouraging.
But it was clear that the rural internship programmes were in serious
trouble. Rural health centres for training interns had been started
without adequate planning, staffing, equipment, or accommodations.
Interns expressed their resentment forcefully in statements such as,
“The one thing I have learned is that I am never going back to a village
again.” Many faculty members ridiculed the experience alleging that
the rural internship was doing more harm than good. It was obvious
that interns were bored because they did not have enough to do. The
tasks they were assigned seemed irrelevant to their career goals. Too
much of their time was spent observing the work of others. The
8
The Need for Research in Rural Health
Doctors for the Villages
negative feelings were strongly reinforced because many of their
teachers had no conviction about or knowledge of the purposes and
rationale of rural health teaching programmes. Takulia (1967)
recorded tire fact that clinical teachers had almost no understanding
of the realities of rural health work and were unsympathetic and often
openly antagonistic to the teaching time and resources allocated to it.
Even more significant was the finding that a substantial proportion of
the teachers of preventive and social medicine also lacked commitment.
For example, thirty-seven percent of teachers of community medicine
considered curative work to be of higher priority than preventive work
in primary health centres.
It is not surprising then, that difficulties were encountered in
starting rural internships. This was a new and pioneering venture. No
one in the world had significant experience with this sort of teaching.
Inevitably, there were negative comparisons with hospital internships.
In a way, this was unfair since the latter had evolved internationally
through many years of hospital-based teaching (Mumford 1970).
Even more serious was the fact that there was no clear definition
of the role that a doctor should play in a health centre team or, for
that matter, how a health centre should provide community health
care (Adair and Deuschle 1970). Again, the legitimate uncertainty
about patterns of activities in rural community medicine was compared
negatively with the highly systematized hospital services and with
physicians’ office practices which had evolved over centuries (Lyden
et al 1968).
After the survey in 1959, the Minister of Health asked whether
we would organize a collaborative research project with Indian medical
colleges to learn more about problems of preparing doctors for rural
service and developing a rural orientation as part of medical training,
and about possible solutions to such problems. Over a two-year period
we worked out research plans and obtained support through a PL-480
grant from the Bureau of Educational and Cultural Affairs of the
United States Department of State.
To study the rural orientation of physicians, we decided that
tire project headquarters should be based in a village environment. As
in psychoanalysis, we felt that our research staff should experience the
process of adapting to village work in order to be able to study others
going through it. An important by-product was the fact that the
requirement that we all live in villages served as an effective and
automatic screening device in staff selection.
9
Origins of the Rural Health Research Project
1
The village of Narangwal became the site of the Rural Health
Research Centre so as to be near the Ludhiana internship program.
It was here that, in 1955, Sardar Prahlad Singh Grewal had asked the
Christian Medical College to take responsibility for running a twenty
bed rural hospital that he was constructing in his home village as a
memorial to his son, Bhagwant. This attractive and efficiently
designed teaching health centre provided an appropriate base for the
new rural internship programme. The Department of Preventive and
Social Medicine was already teaching undergraduate medical students
in three other rural health centres.
We started field work in the fall of 1961, with a one-year pilot
study. We undertook to run the Ludhiana Christian Medical College
rural internship programme at Narangwal during this year while work
ing out the research methods. The core staff was gathered. Using the
Narangwal interns, we tried out innovative approaches to organizing
rural teaching programmes. Even more important for the research, we
developed a wide range of testing procedures to measure the effects of
the rural learning experience. From multiple pretests, and after
discarding many good ideas that proved difficult to implement, we
developed a structured battery of tests.
Members of the core team visited medical colleges in all parts of
India to select seven colleges with well established rural internship
programmes to be included in the study. Logistic reasons made it
impossible to select a random sample of Indian medical colleges. Three
criteria formed the basis for selecting colleges: interest in participating,
geographical distribution, and representativeness in the distribution of
types of institutional affiliation and support. Further stages of the
field work are described in more detail in Chapter 2. The project was
moved from Harvard to Johns Hopkins in the spring of 1962 as one of
the first major field activities of the newly organized Department of
International Health.
Objectives of the Rural Internship Study
,
The rural internship is a particularly significant time to study
doctors’ rural orientation. First, it comes at a critical period when
most young medical graduates are deciding the direction that their
10
Doctors for the Villages
careers will take. Second, it is the first major block of time in medical
education during which doctors are involved in intensive village work.
For many young doctors, moreover, it is their first experience of
actually living in a village. Lastly, it is legally required of all medical
graduates by the Indian Medical Council.
The research was designed to pursue the following objectives:
1. To discover the relative salience of factors affecting
acceptance or rejection by interns of rural training and careers in rural
health service.
2. To suggest ameliorative measures for training procedures
in medical colleges and criteria for selection of medical students to
increase the probability of better recruitment for rural health services.
3. To define the more important and feasible changes in
tire organization of health centres that will make service in them more
attractive to physicians.
Other Narangwal Research
Study of Health Centre Doctors
During the five-year rural internship project we also conducted an
associated study which has already been reported in the monograph
The Health Centre Doctor in India (1967). Discrepancies in official
statements about the health centre doctor’s role prompted this study.
We obtained profiles of role expectations by in-depth interviews with
the health officials and educators most directly responsible for policy
decisions relating to PHC doctors. These were compared with the
experiences and opinions of the PHC doctors themselves. The'.
comparison of expectations with the practical problems that had arisen j
provided a logical basis for further planning. Samples of six groups of'
important decision makers (legislators, senior administrators in central
and state health services, district-level administrators, clinical teachers
in medical colleges, teachers of preventive and social medicine, and
PHC doctors) from all over India were interviewed using an interview
guide. Tremendous discrepancies were found in their knowledge of
and opinions about the problems of rural health. Legislators and
clinical teachers, for example, knew almost nothing about primary
The Need for Research in Rural Health
11
health centres.. Senior state or central government administrators,
district level administrators, and teachers of social and preventive
medicine had somewhat better understanding. Their expectations,
however, were unrealistic in that the health centre doctor was expected
to do everything for everyone, and all the jobs to be done were simply
assigned to him. Their attitudes were crystallized in the long lists of
responsibilities itemized in the various manuals which had been
written to “guide” PHC doctors in health centre work.
The standard against which all of these opinions were judged
was made from the responses of health centre doctors themselves.
It was found, however, that when faced with an impossibly complex
and massive workload, the PHC doctor held on to curative work as his
first responsibility. His training and understanding of professional
ethics led to an automatic acceptance of the primacy of acute curative
care, with little effort to balance off relative priorities to be assigned
to community problems. When asked to calculate the average time
spent with each patient, one-third said that it might be only thirty to
sixty seconds per patient. On the other hand, three-fourths of the
doctors agreed that five minutes was the minimum time which should
be allocated to each patient. The analysis led to a number of practical
recommendations, many of which are already being implemented in
various states of India.
Beliefs About Diet and Disease
Because we had seven Indian social scientists living in village
health centres in various regions of India, we had a unique opportunity
to study the beliefs of village people about diet and disease. Medical
practitioners in both rural and urban practice have little understanding
of the health beliefs of the general public. Yet, to be themselves
understood by villagers, doctors often need to explain prescribed
treatment and prevention by reinterpreting local beliefs. Particularly
important are beliefs about food because Ayurvedic teaching closely
links diet with health and disease.
Most medical students receive a western-oriented,
scientific
clinical education which pays little attention to social and cultural
factors. In fact, by directly or indirectly ridiculing popular beliefs,
most scientifically oriented physicians seriously damage their rapport
with patients. Their explanations, in scientific shorthand rather than
in terms that people understand, make it unlikely that patients will be
12
Doctors for the Villages
able to cooperate fully in their own treatment. Such beliefs are not
limited to village people. Many urbanized and educated Indians share
in the strong Ayurvedic tradition and patronize the Vaidyas and other
indigenous practitioners (Leslie 1969). Even when they come from
homes which reflect traditional beliefs, many doctors show embarrass
ment when Ayurvedic beliefs are mentioned and pretend to be ignorant
of them. Even worse, they may condescendingly assume that all local
beliefs are the same as their own childhood interpretations of what
they remember hearing their grandmothers say.
Our study systematically studied local patterns of beliefs about
selected diseases and diet in rural India. Data such as these can provide
medical students with a basic framework on which they can build their
own more detailed understanding of the particular cultural milieu in
which they will practice medicine. A book, now being written,
records our findings and shows the geographic variations in patterns
of belief in the different areas of India studied.
Studies in Other Countries
The battery of tests developed for the rural internship research
at Narangwal has been used since in comparative studies. In Turkey
(Taylor et al 1968), the need to recruit doctors to staff government
rural health centres in Eastern Anatolia became a particularly critical
issue. Little was known about the attitudes of Turkish doctors. The
battery of tests was therefore applied to the following samples: recent
graduate physicians who were just joining the national health services
to work in rural health centres; doctors who had been working in rural
health centres for one year; rural practitioners with long periods of
work in private practice or government dispensaries; hospital residents
in teaching hospitals in Ankara. A similar study was then done in Iran
(Mehra 1969), where the following groups were sampled: physicians
serving in rural clinics of the Imperial Social Service Organization with
more funding and support; physicians serving in the “health corps” as
alternative service to a two-year required military obligation; residents
in Teheran teaching hospitals; final year medical students; first year
medical students. A third study is now under way in Tanzania among
rural medical assistants. Preliminary comparisons of findings from
these studies show remarkable similarities in the problems of recruiting
and preparing physicians for rural service.
The Need for Research in Rural Health
13
Current Research Projects
As the five-year research project reported in this book neared
completion, three other research projects were developed concurrently
at Narangwal. Their preliminary findings have contributed greatly to
the conclusions reported here and, for this reason, a brief summary
seems appropriate.
All three projects evolved from this rural orientation study. It
had become evident that only limited progress could be made in rural
health by concentrating on doctors alone. The whole health team was
important and the gaps in providing health care could really be filled
only by auxiliaries. The present health centre system provided a 1
general framework for regionalized services, but there was an almost 1
complete vacuum between the health centre and the village home. It
was also apparent that a rural orientation could not be effectively
provided for physicians until the role relationships of the whole health
team had been defined and we knew how doctors might function as
team leaders.
The Functional Analysis Research Project, therefore, concentrated
on a systems analysis of the whole health centre complex. The major
objective was to develop a methodology for relating health needs to
resources.
We developed a functional matrix based on thirteen
functions. Data were systematically gathered through household inter
views to define need in accordance with these functional terms.
Similarly, streamlined work sampling provided measurements of the
way health resources were being used. Since the same functional
categories were used, it was then possible to work out better ways of
allocating the scarce resources. Detailed studies in Punjab and Mysore,
as well as in three provinces in Eastern Turkey, provided an inter
national validation of the methodology (Reinke et al 1973; Reinke
et al 1974). Further streamlining of the methodology has made it
feasible to be used as a new basis for data gathering by the planning
and evaluation cell of the Punjab Ministry of Health in India (Punjab
Directorate of Health and Family Planning 1973).
The functional analysis project was primarily observational, in
that it studied existing government services and provided recommend
ations for progressive improvement. The other two projects were
action research. In both instances, new patterns of services were
developed and applied in groups of villages within an experimental
design. Comparative input-output measurements were made so that
s,
14
Doctors for the Villages
the costs and benefits of different programme components could be
analyzed. Rather than just modifying existing services, we made a
deliberate effort to be innovative, trying out new comprehensive care
approaches. In both instances, the design permitted the testing of
basic hypotheses relating to what we considered to be the two greatest
health problems of Punjab villages.
One project was concerned with the interactions of malnutrition
and infections in weaning-age children. The four cells of the experi
mental design included groups of villages receiving: (1) nutritional
supplements only, (2) infection control services only, (3) both of the
above, and (4) neither nutritional nor infection control services.
Although the data are not yet completely analyzed, it is already clear
that child mortality was reduced by half in villages where nutritional
supplements and infection control were combined. It declined less
dramatically in the groups where only one or the other type of service
was provided. A clear improvement in growth and development was
demonstrated in the populations of children receiving nutritional
supplements. Anemia was dramatically reduced.
The other project was to study the interactions of family
planning services, maternal care, and child care in increasing family
planning practice. We set out to measure the comparative effects of
different combinations of services.
The five experimental cells
included: (1) family planning, maternal care and child care; (2)
family planning and maternal care; (3) family planning and child care;
(4) family planning only; and (5) control. Among the hypotheses
being tested we are particularly interested in the child survival
hypothesis—that parents will not stop having children until they are
assured that those they already have are going to survive. We have
demonstrated that in an area where only ten to fifteen percent of
eligible couples are practicing family planning we can get continuous
utilization rates up to thirty-five to forty-five percent of eligible
couples.
Along with the above basic research objectives, in these two
projects, we have had a parallel flow of subsidiary applied research
aims. To have an input for the experimental design, we had to develop
new service packages. This required the progressive refinement of
alternative field approaches through serial testing under practical
conditions. What evolved was quite different from the original service
packages that we had proposed theoretically. The most important
change in this process of evolution was the redefinition of the role of
The Need for Research in Rural Health
15
the auxiliary nurse midwife. New job analyses and descriptions led to
major changes in approaches to their training.
These projects are at a stage where the findings can now be
implemented in demonstration, projects and then more generally
throughout India.
Summary
The studies carried out by the Narangwal Rural Health Research
Centre have been closely integrated at all stages with the Indian
government’s commitment to, and tremendous investment in, rural
health services. The need for intensive research, both basic and applied,
is apparent because India’s efforts to develop rural health and family
planning represent one of the most significant public programmes
being undertaken in the world today. Dr. P.R. Dutt has stated the
ambitious goals (1963):
A system of primary health centres throughout the
country reduces the need for hospital beds, changes the
pattern of hospital admissions, reduces the expenditures
on the treatment of the sick, provides a solid foundation on
which the whole edifice of preventive and promotive health
can be built and enables the exponents of public health to
take their learning into the very homes of the people,
where health practices must be taught and learned.
Such a tremendous health revolution will not happen spon
taneously. Field research, such as the project reported here, must
be linked closely with health planning, innovative demonstration
projects in administering health and family planning services, and new
approaches to the education of all health and family planning
personnel.
Methodology of the Research Project
17
Hypotheses
2
Methodology of the
Research Project
Innovative adaptation of behavioral science research methods was
needed to get information about the following two questions:
What is the attitude of young medical graduates toward rural service
and what factors influence these attitudes? What is the impact of the
rural internship, especially since it is the first prolonged exposure to
villages and rural health service for most young physicians?
A common human reaction to complex issues is to oversimplify.
Certainly this has been true of attempts to understand the problems of
attracting and preparing physicians for rural service. When we were
preparing for this study we frequently encountered health administra
tors who said, “There are three reasons why doctors do not go to
rural areas.” The more administrators we talked with, the more
obvious it became that most had different sets of three reasons. In the
first stage of research, therefore, we attempted to classify these varied
explanations of the problems of rural service into specific hypotheses.
This general conceptualization required an interdisciplinary approach
based both on broad understanding of rural medicine and medical
education, and the processes of professional socialization.
For data gathering, we primarily relied on questionnaires and
two projective tests. A complete battery of tests was administered to
all interns during the first week of their rural internship, and again
during the last week to measure the effect of the rural posting. Each
year the data were analyzed and the results presented to a conference
of Indian medical educators and government officials so that the
rvx'.uvr. effort profited from the contributions of more than 100
of India’s medical leaders.
s
In the exploratory phase of the study we cataloged the subjective
impressions of knowledgeable medical educators and health admini
strators relating to the attitudes of doctors toward rural service and
tried to determine why they held these attitudes. These observations
were presented at the First Conference on Rural Internships held in
Narangwal in April, 1962. Prominent Indian and international experts
in the social sciences, medical education, and health services admini
stration met to evaluate the preliminary efforts and to provide collect
ive guidance for the development of the research design.
In the opening session, we presented the seventy-nine distinct
reasons why young physicians were reluctant to enter rural service that
had emerged during our exploratory survey. Working groups were
asked to establish priorities and to select a few important variables
that could be stated as testable hypotheses. After a full day of
discussion, the conference members had discarded none but had added
one—to arrive at eighty variables. They were also unable to place them
in any rank order of priority because each item had its strong advocates.
The items were merely classified under six headings: (1) attitudes of
interns; (2) attitudes and influence of intem’s family and reference
group; (3) professional and career opportunities; (4) rural living
conditions; (5) attitudes toward villagers; and (6) instruction during
internship. From the eighty items, the following were formulated as
hypotheses that could be tested in this study (c complete list of
hypotheses appears in the Appendix).
1.
Attitudes of Interns
a. Interns will be more attracted to rural health services
if they are:
1) patriotic
2) acquainted with village life
3) men, rather than women
4) in urgent financial need
5) religious and humanitarian in their outlook
b. Women interns are less attracted to village services
(than men) because they are:
1) concerned about their personal security
Doctors for the Villages
18
less willing than men to tolerate uncomfortable
living conditions with greater problems in main
taining personal grooming.
10)
11)
12)
Attitudes of Families and Other Reference Groups
a. Parents will encourage their sons and daughters to
enter rural service only if it becomes a prerequisite to
advancement in government service or academic ap
pointment.
b. Those interns who perceive their parents as unfavour
able to rural practice are less likely to have favourable
attitudes toward rural service.
c. The more doctors in the intern’s family, the less
willing he will be to enter rural service.
d. Those doctors who perceive their spouse’s attitude as
negative to rural work are less likely to have favourable
attitudes toward rural service.
e. 'fliose interns who perceive their reference groups as
attaching low prestige to preventive services are less
likely to have favourable attitudes toward rural service.
13)
2)
2.
3.
Methodology of the Research Project
Professional Opportunities
a. Service conditions - interns will be more likely to
accept service in a primary health centre if:
1)
this experience is seen by them as contributing
to their professional advancement (i.e., in govern
ment service).
2)
this experience is a pre-requisite to postgraduate
courses.
3) they can attend professional meetings and refresher
courses.
4) the health centres have adequate drugs and
supplies.
5) services of consultants are available.
6) the health centres have adequate equipment.
7) the health centres have an adequate supply of
journals and books.
8) the health centres have adequate buildings.
9) patient load is not excessive.
14)
15)
16)
4.
19
clinical experience is varied and interesting.
technical assistance is adequate.
it can be demonstrated that they will not lose
basic clinical skills.
they are assured that the preventive skills which
are learned are appropriate components of good
medical practice.
they are better informed about the responsibili
ties of health centre physicians.
they have opportunities to engage in research.
they are under medical supervision rather than that
of non-medical community development officers.
b.
Work opportunities — interns will be more likely to
accept service in a primary health centre if they see the
rural service as:
1) an opportunity to combine curative and preventive
work.
2) providing medical care to needy people.
3) permitting personal independence in arranging
their own schedules.
4) meeting a national need.
5) an opportunity to assume administrative respon
sibility.
6) an opportunity to serve large groups.
7) an opportunity to study whole communities.
8) an humanitarian service.
c.
Interns will prefer the types of practice for which they
feel they are prepared.
Living Conditions
Interns will be more likely to accept rural health service if:
1) housing in primary health centres is adequate.
2) health safeguards for their families are available.
3) provisions are made for schooling for their children.
4) transportation is provided.
5) recreation and social contacts are available.
6) pay is increased.
Doctors for the Villages
20
5.
Attitudes Toward Villagers
Interns are more likely to accept rural service if their
attitudes toward villagers as people are favourable.
6.
Instruction During Internship
a. Interns will be more likely to react favourably to
rural health service if:
1) instructors reside in villages and set standards of
adjustment to living conditions that can be achiev
ed by other doctors.
2) the intem’s activities include participation with
responsibility under supervision rather than mere
observation.
b. Interns will be attracted to careers in rural health
service if their internship has provided a satisfying
experience in:
1) clinical work with common diseases which are
usually screened out of practice in the teaching
hospital.
2) use of simple diagnostic measures.
3) use of simple therapeutic measures.
4) development of ecological understanding in eval
uating patients and their needs.
5) application of preventive measures in clinical
practice.
6) understanding emotional problems in patient and
family care.
' 7) understanding the medical economics of patient
and family care.
8) the concept that the patient of tire health centre
physician is the whole community.
9) learning routines of work in a primary health
centre.
10) research experience in field projects.
11) using records which are well-planned, efficiently
maintained, and used in daily work.
c.
Academic performance in the medical college has no
predictive value for the quality of performance in the
healtli centre internship.
Methodology of the Research Project
21
The hypotheses were stated in terms that permitted the construc
tion of quantifiable indices as part of a set of questionnaires. These
were supplemented by psychological tests. Some of these hypotheses
were obviously more readily studied than others. It was not possible to
mount in-depth studies of the villagers being served, of the few
teachers involved, and a continuing follow-up of the interns’ subse
quent job selection and performance. We were surprised, however,
by the range of variables that we were able to include as a result of the
careful preliminary analysis. The most useful aspect of this broad
approach was that it permitted us to place variables in comparative
scales of relative importance.
Many different methodological approaches were tried during
initial stages of the study—including daily diaries, in-depth interviewing,
spot observations for work sampling, and various approaches to evalating field performance. The forms which appear in Appendix A are
those used through the three years of definitive observation. A brief
description of each form follows:
Battery of Questionnaires and Tests
Identification Sheet
General information on the social, economic, academic, rural/
urban, and professional background of the intern and his family was
obtained and recorded on this form for cross-tabulation with other
variables.
Form I — (Rural Thematic Apperception Test)
This instrument is an adaptation of the Thematic Apperception
Test (TAT).
It was developed in consultation with Drs. David
McClelland, David Winter and George Litwin of the Department of
Social Psychology at Harvard University. The test consisted of
pictures drawn by Dr. Bal Jerath of the Ludhiana Department of
Preventive and Social Medicine to portray an individual who might, be
interpreted as a physician in a variety of village situations. Interns
were asked to write short stories about each of these pictures. The
validated assumption behind such tests is that individuals identify
with a character in the picture and, in constructing a story involving
22
Doctors for the Villages
Hi at character, express their own fundamental attitudes, values,
beliefs and concerns.
Although the TAT had its beginnings as a psychoanalytic pro
cedure, it has since been used for a variety of purposes—such as
analyzing personality traits, assessing social attitudes, and measuring
need for achievement. In the present study, the technique was used to
measure the attitude of medical interns toward living and working
conditions in the village and toward the village people. Their responses
also indicated generally their approach to coping with problems arising
out of rural service. Unlike the pictures used in Thematic Apperception
Tests for personality assessment, these pictures were drawn to elicit
specific responses to a suggestively rural setting. The unstructured
diffuse stimulus provided by tire vague pictures of the standard TAT
enhance their value for the assessment of personality, but they have
limited value when the purpose is to measure specific attitudes or
traits. Under such conditions “...apparently the most significant
information is elicited by pictures that are structured to suggest a
particular emotion or conflict, though not so explicit that every
subject tells the same story” (Cronback 1970). Apart from the
pictures themselves, the usefulness of tire technique depends upon two
major factors which will be discussed briefly: first, upon the way the
test is administered, and second on the coding and analysis of tire
protocols.
From among twenty-four pictures which were originals, drawn for
the purpose, two sets of six pictures each were assembled after
elaborate pretesting. The two sets contained pictures matched for the
type of responses they evoked from interns in relation to the attitudes
that we were interested in measuring. One set of pictures was then
given at the beginning of the rural internship and the other at the end
of the internship, with tire order of administration being reversed for
each successive group of interns. The instructions for the test were
matter-of-fact and straightforward. Four simple questions urged the
interns to use their imagination to construct a short story.
A coding manual for analyzing the content of the stories was
developed laboriously from the protocols completed during the pilot
phase of the study. Even the designation of specific attitudes was
permitted to emerge from the code construction rather than being
decided beforehand. Five coders did the actual coding of the definitive
study protocols. These were individuals selected for their scoring
Methodology of the Research Project
23
reliability during the training sessions. Two teams of two coders each
were formed. Members of a team independently scored the protocols.
Any substantive disagreement on the scores was resolved by the fifth
coder who acted as the arbiter. This elaborate procedure was used to
maximize standardization.
Form II — (Questionnaire on Professional Matters)
Interns were asked to express their opinions on specific questions
by checking along a four-point scale. The questions in Form II related
to preference for various medical specialties, interest in professional
activities, self-assessment in professional skills and abilities, expected
income after ten years, and conditions under which interns would be
willing to serve in rural areas.
Form III — (Questionnaire on Rural Programme)
This form contained five questions when administered at the
beginning of the internship and seven when given at the end. Interns
were again asked to express their opinions by checking on a three or
four-point scale. These questions asked about the importance of
factors which influence favourably or unfavourably the choice of rural
service, functions considered appropriate for primary health centre
physicians, impressions about villagers, worthwhileness of various
activities in the rural training programme, knowledge gained during
internship, and suggestions for improvement of rural training pro
grammes.
Form IV — (Story Completion Test)
Like the TAT, the Story Completion Test was a specially con
structed psychological test in which interns were given a set of stories
which had been started but left unfinished at a crucial decision point.
Each story posed a serious problem that might arise in rural work. The
interns were asked to complete the story, thereby revealing their basic
reactions in a specific standard situation. The conceptual and analytic
assumptions underlying this test are in general similar to the TAT. Two
matched sets of stories were constructed and used alternatively before
and after internship.
Doctors for the Villages
24
Methodology of the Research Project
25
quickly became apparent that the colleges correctly developed the
feeling that this was “their” project.
Daily Log
The Daily Log, designed to record the amount of time the intern
spent on various activities, was used only during the first year of the
study. It was discontinued because clear patterns had already emerged
and because filling out the form proved to be a significant burden to
the interns.
Supervisors Check List
An attempt was made to get the supervisor of each internship
programme to fill out a form evaluating each intern. This also proved
to be too much to expcet of all supervisors, and therefore the proced
ure was discontinued after the first year.
Selection of Medical Colleges
Rural internships could be studied only with the active coopera
tion of medical colleges with rural training centres. There were sixtyfour medical colleges in India in 1961, only half of which had an active
rural internship programme. A prolonged series of visits to medical
colleges permitted in-depth discussion of relevant issues. The process
and criteria for selection and the medical colleges selected are described
in the next chapter. We selected the seven, colleges so as to get a
distribution of identifiable characteristics in established programmes
as well as willingness to participate. The final choice was necessarily
somewhat arbitrary, since no effort was made to randomize the
selection process. More than with most sampling, we found it difficult
to define clearly distinguishable parameters of representativeness; there
seemed no straightforward way to randomize even within stratified
groups. The eventual decision was to rely on personal judgement about
representativeness, since this had to be only one factor in complex
negotiations about cooperative relationships and the distribution of
effort. A continuing interaction with medical colleges all over India led
us to feel that our deliberate selection did, in fact, provide a reasonably
representative sample of the better rural internship programmes in
India. There was no point in studying programmes which were only
being planned or had barely begun. The choice of medical colleges
proved especially good for the research team because of the gratifying
continuing level of cooperation and mutual support that developed. It
Project Staff
Our initial strong conviction was that the project headquarters
and project staff must be based in a rural environment. If we were
going to understand rural conditions clearly, it was necessary that the
staff should personally experience rural life and working conditions.
Many valuable lessons were learned and observations made just because
most of our staff lived in the villages where the interns were stationed,
and this led to close daily associations. This would not have occurred
with only occasional or even daily visits to a village teaching centre
from an urban base.
The project headquarters were set up in Narangwal, a predom
inantly Sikh village fifteen miles south of Ludhiana. Great pains were
taken to remodel village houses so as to provide the staff with safe,
sanitary, and relatively pleasant housing.
Tire field staff responsible for data collection were Indian social
scientists.
Seven were selected from the linguistic areas of the
cooperating medical colleges. They had been trained variously in
sociology, economics, political science, social work, and anthropology.
A social scientist was assigned to work in the rural training centre of
each medical college where he observed the interns during their daily
work. His main responsibility was to administer the battery
of
test forms at the start and end of the internship. He also studied the
area and the health centre, and gathered data for the study on beliefs
of villagers about diet and disease.
Data Collection
In each teaching centre, the social scientist was responsible for
arranging times when the interns as a group could complete the
questionnaires in his presence. The social scientist frequently re
iterated to the interns emphatically that he was not on the staff of
their medical college and that answers would not be shown to medical
college teachers. Interns were assured that their responses were
strictly confidential and that questionnaires would be mailed directly
to the project headquarters at Narangwal. To further convince the
interns of the confidentiality of the responses, code numbers were
26
Doctors for the Villases
used to identify forms. The interns wrote their identification data on
a perforated section of the coversheet of the test instructions. This
part was detached from the questionnaire in their presence after the
test was completed, with subsequent matching being only by codfe
number.
The questionnaires were administered to interns within the first
few days after their posting to the rural centre or, at the latest,
within the first week. This first round of responses is referred to as
“before. ” Similarly, questionnaires were administered during the last
week of their stay in the rural posting; these responses were referred to
as “after. ”
A one-year exploratory study to develop the experimental design
and work out measurement methods was followed by a year of pilot
study to establish local bases in the seven colleges, train the seven
social scientists, and get field procedures established. The definitive
study started July 1, 1963. Data were collected over a period of three
full years from a total of 1,480 interns from the seven cooperating
colleges.
The analysis of the data was supervised by our staff statistician.
Most of these were processed in Calcutta at the Indian Statistical
Institute. The particular advantage of having analyses done as the study
progressed was that it provided a periodic review of data for discussion
at tire annual conferences.
We used two approaches in analyzing the data. First, crosstabulations examined the relationships between the attitudes of interns
and tlie independent variables included in the study. Second, scores on
items were compared on the basis of “before" and “after" responses.
It was assumed that changes in scores were attributable to the rural
internship programme. This assumption must admittedly be made
with some reservations. Deeply embedded resistance to rural service
obviously could not be removed in an internship programme
that
lasted from six to twelve weeks. The testing procedures could also
introduce error since the survey instruments were being repeated within
a relatively short time interval. The assumption, however, seemed
justified because we expected some major changes in the parameters
under observation. Most interns had little prior first-hand experience
with rural living or rung medical service. That the experience had a
significant impact was evident from simple observations. The selective
changes in responses which were, in fact, observed seemed reasonably
related to their overall experience. Interpretations were made mostly
Methodology of the Research Project
27
by our collaborators in the medical colleges and government. In
addition, the state of the art of social research and practical problems
of feasibility offered us no real methodological alternatives. Although
tire effects of the internship programme were, no doubt, confounded
with some random variation in response, we had to depend on the other
means of maintaining analytical objectivity which were established.
Such random variation would be more likely to reduce rather than
accentuate differences. We could, of course, also compare our results
with other research to make inferences about the significance of
changes over time. Ideally, one might have desired a factorial design
wherein some interns would go through the program while the others
could be studied as controls. But this was not possible, since the rural
internships were legally required of medical graduates.
Some of the data are useful mainly to show descriptive profiles
rather than differences. In these instances it is the patterns of responses
that are most illuminating. All findings that are reported in this volume
as measured differences in comparisons between groups, or before and
after results, can be accepted as being statistically significant. They are
based on calculations derived from mean scores on four-point scales
for particular items. For specific comparisons between groups, our
calculations show that with groups of the size involved here, a useful
and conservative rule of thumb is to say that any difference in mean
scores of more than 0.15 may be taken as probably significant. We
again stress the fact that our sample of medical colleges is not a »
representative sample of all Indian medical colleges. Caution must
therefore be exercised in extrapolating these descriptive findings to
medical education and interns in India generally.
To facilitate understanding, the data are presented mainly in the
form of bar graphs. The length of each bar graph represents an average
of the scores assigned by interns to a particular item on the question
naire.
(
,
I
Annual Conferences
>
Particularly useful in getting rapid implementation of the findings
of this project was a series of annual conferences held in February of
1963, 1964 and 1965, with a final conference in November, 1966.
These conferences were organized primarily for collaborators from the
seven medical colleges participating in the study. Those attending
regularly were the dean or director of each medical college, tlie
JJoc.ors for the Villages
professor of social and preventive medicine, and the health officers in
charge of the rural health centres where the internships were conducted.
In addition, these conferences were regularly attended by selected
senior health officials from each of the states where these colleges were
located. The health Minister during these years was Dr. Shushila Nayar,
whose personal interest in this rural problem was so great that she parti
cipated with enthusiasm and provided continuing support to ensure
implementation of the research. Other officials from the Central
Health and Family Planning Ministry, the Indian Medical Council, the
Indian Council of Medical Research, and multiple international agencies
such as WHO, AID, and foundations provided stimulating insights and
practical guidance.
The conferences served dual purposes.
First, the raw data
collected up to a couple of months before the conference were
presented to discussion groups. They analyzed the year’s findings and
interpreted their meaning and relevance. This also proved tremendous
ly important in improving and maintaining the quality of the research.
Second, the findings initiated open discussion of multiple pro
blems related to the doctor’s role in rural work. The most valuable
practical contribution of these conferences was that they brought
together senior administrators and medical educators who were con
cerned with rural health in a series of increasingly frank exchanges.
They had an opportunity to base their discussions on facts rather than
speculations and to share their impressions and experiences. They went
back to their own jobs with new ideas to try out and with the stimula
tion derived from the assurance that other experts were also working
on the same problems. Then they could meet again after a year to
carry forward the sharing of experiences growing out of efforts to
implement their findings. It proved very gratifying to hear some of
them greet each other with, “You know what I tried last year and it
works!”
Just as it was important for the staff to live in rural areas, it also
proved especially valuable for the conferences to be held in the village
setting of Narangwal. Most of the conference participants lived in tents
for three days; others stayed in the village homes of our staff. We ate
and held our meetings under brightly colored shamianas (tents).
Mainly as a result of these conferences, the research project truly
came to be considered “our own research” by the seven medical
colleges and the health officials who participated. The evolving club
atmosphere was best shown by the contrast between the first confer
ence and the last. In 1963 the staff had to defend the project and the
Methodology of the Research Project
2P
methodology. The 1966 conference was held the week before the
Third World Conference on Medical Education in New Delhi and
attracted some thirty international experts in addition to the regular
conference group of about fifty. The project staff was gratified to
find that the whole burden of explaining project rationale, constraints,
and approaches was taken on with great conviction and enthusiasm by
conference participants from previous years.
Further Studies
In the years since the specific data collection on rural internships
was completed, there has been a major effort to evolve solutions for
the problems defined. The Narangwal research has moved forward on
several fronts to work out reasonable and practical positive approaches
to primary care in rural areas. This information is synthesized in
Chapters 8 and 9.
The Seven Cooperating Medical Colleges
31
Christian Medical College, Ludhiana
The Seven Cooperating
Medical Colleges
This study of the attitudes of interns toward rural service and toward
their training in rural medical care was possible only because of the
cooperation of the seven medical colleges participating in the research.
The Departments of Social and Preventive Medicine in these colleges
were particularly generous in their interest and support.
In selecting the medical colleges, several variables were balanced to
select deliberately for characteristics that would represent the various
types of colleges in the country. Specifically, we took into considera
tion: geographic distribution, source of financial support, administra
tive organization of the teaching health centre and its relationship with
government health services, size of the city in which the medical college
was located, size of classes, financial support of medical care activities
in the teaching health centres, duration of internship, and ratio of
clinical to preventive activities. Most important were indications of
enthusiasm and commitment to the research on the part of the medical
college authorities and the Departments of Social and Preventive
Medicine. Some pertinent characteristics of the cooperating colleges
are given in Table 3.1.
The outstanding generalization that emerges from a look at the
seven colleges and their rural internship programmes is the tremendous
variation in all identifiable variables. In fact, there were so many major
differences that it became almost impossible to characterize special
aspects of individual programmes or to analyze for particular program
me components. It is little wonder that there is uncertainty about
what a rural internship programme should include.
For sixty years, the Christian Medical College in Ludhiana was a
mission-supported women’s college providing licentiate training. It was
upgraded to the full M.B.B.S. course and made coeducational in 1951.
At the time of the study, fifty percent of the students were women.
Most came from small towns and almost thirty-three percent were from
rural areas. Seventy-one percent of the fathers and twenty-five percent
of the mothers had a college education. The high proportion of
physician-mothers
probably represented alumnae of the school.
Fathers were employed in a wide range of occupations, mostly middle
class. But almost sixteen percent of the students came from poor
families (i.e., families with less than Rs.200 per month income). Over
one-third of the students were Christian; one-third were Hindu;
one-tenth were Sikhs, and another tenth were Muslim.
Rural Internship
The rural internship programme was started in 1956 at the
Bhagwant Memorial Health Centre in Narangwal, a village of 1,800 pop
ulation, fifteen miles from Ludhiana. The health centre consisted of a
well-constructed brick building on beautiful grounds with a 25-bed
inpatient facility and outpatient and preventive clinical sections.
Quarters for the staff and interns were adjacent. A jeep was always
available for their use. A resident physician from the Department of
Social and Preventive Medicine, who was in charge of the health centre,
was responsible for the clinical work and for the interns’ training.
During most of tire study period, a female doctor also worked in the
clinic with the interns. The usual complement of supporting personnel
completed the staff.
Internship Programme
Interns spent two months of a six-month rotating internship at
Narangwal, and were required to participate under supervision in the
following activities:
1. Outpatient and Inpatient Rotations: General clinics were
held daily. From time to time, some specialty clinics were held by
physicians visiting from the college—including medical clinics, eye
32
Doctors for the Villages
clinics, and occasionally a surgical clinic. In addition, every year an
eye camp took place, during which many cataract and trachoma
operations were performed. For inpatients, the intern responsible for
admitting a patient also followed him through the hospital stay and at
home when necessary. The patient load was not heavy, in spite of all
these facilities. One reason was that patients resented having to pay
I for services because they were used to getting free services at goveml ment institutions. The faculty members were, obviously, trying to
maintain a medical college level quality of care in the rural setting,
even though their visits were intermittent.
2. Research and Survey Projects: Interns individually or in
teams of two, planned, carried out, and wrote up a research project.
Findings were presented and discussed at a series of seminars held near
the end of the internship. Emphasis was placed on the ecology and
epidemiology of health problems in the context of local village
conditions. In addition, census data, used in part for statistical
exercises, were collected from neighboring villages.
3. Family Care and Sanitation Programmes: Interns were
assigned “a ward” of fifteen to twenty families in nearby villages,
for whom they acted as family physicians. The interns advised these
families on various aspects of health promotion and disease prevention,
assisted them with sanitation problems (e.g., encouraging them to
install sanitary latrines, smokeless chulas [fireplaces], and soakage
pits), and helped them to get necessary immunizations.
All India Institute of Medical Sciences, New Delhi
During this study, the rural programme had three components:
two weeks in the casualty ward at the Institute, eight weeks at the
teaching health centre in the village of Kurali, and two weeks at the
community development block primary health centre in the town of
Ballabgarh. The Institute started internship training in January, 1961.
The health centre at Kurali, a village about thirty miles from New
Delhi, only had outpatient facilities. Another building in the village
was rented as a residence for the interns and a supervisor. No vehicle
was stationed at Kurali, although a jeep and bus from the Department
of Social and Preventive Medicine visited frequently to transport
interns and faculty. Public bus transportation ran three times a day
The Seven Cooperating Medical Colleges
33
to Delhi and was much used in the evenings. A demonstrator
(instructor) was the resident supervisor. Other staff included one
full-time physician, two auxiliary nurse-midwives, and one pharmacist.
Weekly visits were made by the chairman and faculty members of the
Department of Social and Preventive Medicine, and the Director of
the Institute also made regular visits.
Internship Programme
The main features of the eight-week training program me at Kurali
were:
1.
Clinics: General clinics were held every morning except
Sunday, during which interns examined patients, dressed wounds,
carried out minor surgical procedures and laboratory investigations,
and dispensed drugs and injections. Weekly specialty clinics which the
interns attended included pediatrics, ophthalmology, ear, nose and
throat, and dermatology. In addition, a well-baby and antenatal clinic
was held weekly.
2. Family Care: A block of twenty-five to fifty households was
assigned to each intern, who worked with the village health committee
to provide comprehensive care with special health education program
mes and campaigns.
3. Meetings:- Regular monthly village meetings were held to
increase the interns’ understanding of village problems and to provide
a medium for health education. Once a week, the professor from the
Department of Social and Preventive Medicine came to Kurali to hold
seminars on local and national health and medical problems. A weekly
teaching session with the registrar (senior resident) also was held.
4. Other Duties: Specific morbidity surveys, school health
services, emergency care rotations, and a journal club were also
required activities.
At the time of our study, training at the primary health centre
in Ballabgarh lasted two weeks. Facilitiea were more extensive and
included inpatient wards with sixteen beds. Interns participated in
the following activities: attendance at the outpatient department and
hospital wards, assistance in minor surgery and obstetrical cases,
participation in demographic and vital statistics activities, observation
visits with the block development officer, study of health problems of
a small municipal community, and participation in community health
measures.
Doctors for the Villages
34
At Kurali, about seventy percent of the interns’ time was spent on
clinical work and thirty percent on preventive medicine. At Ballabgarh,
ninety percent was spent on clinical work and ten percent on preventive
care.
King George Medical College, Lucknow
King George Medical College (now known as Mahatma Gandhi
Medical College) in Lucknow is a medium-sized college, supported
completely by the State of Uttar Pradesh as part of Lucknow Univer
sity. A full-time Department of Social and Preventive Medicine was
established in 1958. During the study only fifteen percent of the
students were from urban background, and fathers were well educated.
Twenty-five percent of tire fathers were in business, and family income
was middle-class, ranging from Rs.200-1000 per month. Ninety percent
of the students were Hindu.
Rural Internship
Under the supervision of the Department of Social and Preventive
Medicine, a rural health training centre was started in 1959 at the
village of Sarojini Nagar, a community development block headquarters
twelve miles from Lucknow. Facilities include offices, seminar rooms
and a dormitory for male interns. An adjacent primary health centre
had the usual clinical and public health facilities and a full complement
of government staff, including a physician. There were no inpatient
facilities. Teaching and coordination of field work was under the
charge of a lecturer; the professor of social and preventive medicine
visited Sarojini Nagar regularly for seminars and supervision. Other
members of the faculty visited intermittently for teaching sessions.
The sanitary inspector and health visitor were responsible for most of
tire interns’ activities.
Internship Programme
During most of the study period,
a one-month assignment at
Sarojini Nagar was an elective during the internship year. After July,
1965, however, the rural programme became compulsory and the
posting was increased to six weeks. The original training programme
The Seven Cooperating Medical Colleges
35
was divided between a “participative rotating internship” and “guided
comprehensive community health practice.” When the internship was
extended to six weeks, a community diagnosis and action programme
was added.
1. Participating Rotating Internship: For ten days, interns
observed and participated in the regular work of official agencies.
They visited the community development block to leam about its
philosophy, organization, financing, and functions. At the primary
health centre interns spent one day each, working with personnel
carrying out seven basic functions, including clinics, maternal and
child health care, family planning, etc. Each day’s field visit was
preceded by a lecture and followed by a group discussion with a
staff member. They also visited the government district tuberculosis
hospital in Lucknow and an urban health centre near Lucknow.
After these field visits, a seminar was held and each intern presented
one aspect of the field work. Teaching staff from the medical college
and training centre participated in these discussions.
2. Guided Comprehensive Community Health Practice: In the
second period (twenty days), each intern carried out a detailed
socio-medical survey of three families who had not previously been
assigned to interns. They collected data on the health of individual
members of the family, including laboratory work, and got general data
on income and expenditures, housing, sanitation, nutrition and diet,
morbidity, mortality, personal habits and customs, beliefs and attitudes.
The interns also did smallpox vaccinations and health education to try
to get acceptance of latrines, smokeless chulas, handpumps, and better
handling of water and food. Women interns gave special emphasis to
family planning. Data collected in these family surveys were presented
in a second and third rounds of seminars.
3. Community Diagnosis and Action Programme: During the
final two weeks of rural training, interns studied a particular commun
ity problem. A health education programme, undertaken by the
interns themselves under the guidance of the health educator, preceded
and accompanied the community diagnosis and action programme.
The community diagnosis included surveys for specific diseases (e.g.,
filariasis, evaluation of the effectiveness of mass vaccination against
smallpox, studies of customs in relation to health and disease, investiga
tions of problems in environmental sanitation, and studies of the
functioning of primary health centres. Results of these studies with
recommendations for appropriate action—or occasionally the results
36
Doctors for the Villages
of action programmes actually undertaken—were presented at seminars.
The only clinical work during the rural internship took place
during the ten-day primary health centre rotation. Instead, the training
at Sarojini Nagar emphasized surveys and public health activities.
At the end of the six weeks, interns submitted daily work diaries,
which were evaluated by the lecturer and the head of the department.
In addition, formal assessment of the interns’ work included field work
accomplishments, participation in health education, and presentations
in seminars. After the rural internship became compulsory, in contrast
to tlie other colleges, a student whose performance was judged
inadequate had to repeat the training programme.
Nagpur Medical College
The medical college at Nagpur is a large, state-financed institution.
Students came from relatively poor families and half came from rural
or mixed backgrounds. The only college in the study with a more rural
student body was Trivandrum. Half of the fathers had a college
education, but two-thirds had an income of less than Rs.500 per
month; one-fifth were engaged in agriculture. Almost ninety percent
of the students were Hindu.
Hural Internship
The rural training centre for Nagpur Medical College was located
in the small town of Saoner. The training centre had been set up under
the control of the Director of Public Health in Poona in 1958. In
addition to being the training unit for interns, it was also used for field
training of paramedical wc ’ ?rs for the Public Health Department. It
was twenty-five miles from Nagpur on a pucca road with frequent bus
service, as well as being connected by a narrow-gauge railway. There
was a telephone at the health centre and a post office and telegraph
office in the town.
Tire administrative block provided good residential quarters for
thirty interns, a separate building for public health nurses and students,
and a recreation hall and dining hall. The rather old dispensary
building was owned by the municipal committee of Saoner and had
spacious outpatient facilities and several rooms for inpatients, a small
The Seven Cooperating Medical Colleges
37
room for minor surgery, a small delivery room, a laboratory, and a
pharmacy.
Professional staff included three physicians (although much of the
time no lady physician was available) and a wide range of paramedical
personnel. The doctor in charge had the rank of District Health Officer
and was responsible for both service and teaching at the health centre.
Priority was given to clinical care and formal teaching was minimal.
The professor of social and preventive medicine conducted a seminar
once a week, but other teaching visits by faculty took place only rarely.
Internship Programme
During this study, interns took part in the following activities:
1. Clinical Duties: Supervised clinical work took most of the
time. Every week three interns attended the dispensary and maternal
and child health clinics, where they saw and treated patients under the
supervision of the health centre staff. Other clinics included a family
planning clinic and dental clinic.
2. Village Responsibility: Three groups of three interns each
went on their own to a village for twenty hours per week of clinical
and preventive work. They had to establish their own rapport with the
village leaders, arrange for facilities, and plan their programme. They
saw patients, whom they cared for with a rather simple supply of
medicines. Various educational approaches were tried. The interns
made home visits and provided preventive services.
3. Field Visits: Groups of three interns went out in rotation
with different categories cf auxiliary staff to do routine family planning
work, immunizations, environmental sanitation, and collection of vital
statistics. Each intern also had to study selected families, preferably
those with a member suffering from a chronic illness such as tuber
culosis or leprosy.
4. Seminars:
A weekly three-hour seminar was held on
Saturday mornings, usually conducted by the professor of social and
preventive medicine. This gave the interns an opportunity to discuss
their experiences in preventive work, clinical problems, and information
found in surveys and health unit records.
5. Research Project: During the entire three-month posting,
each intern was expected to devote four to six hours per week to an
individual or group research project.
6. Other Activities: The interns were exposed to a variety of
38
Doctors for the Villages
other experiences associated with the usual activities of the health
centre. For example, they observed tire work of sanitary inspectors,
family planning social workers, tuberculosis technicians, and leprosy
assistants. Some community health education and school health
examinations were done. The interns were supposed to read about
public health and preventive medicine, and a library was provided.
Finally, a summing-up session was held at tire end of the three months
when interns were evaluated and graded, and tire one with the best
overall performance was presented with an award.
Seth G.S. .Medical College, Bombay
Seth G. S. Medical College in Bombay is a large institution
supported by tire municipal government. During the period of this
study, forty-five percent of the students were female, and almost
seventy-five percent had an urban background. Over fifty percent of
the fathers had had a college education; thirty-three percent were in
business. Compared with the other medical colleges in the study
these students were from the wealthiest families. About eighty
percent of the students were Hindu.
Dural Internship
Groups of thirty interns from Seth G.S. Medical College, as well
as similar groups from the other two medical colleges in Bombay, all
served their six-week rural internship at the health unit in the small
town of Palghar. This centre, sixty miles north of Bombay, was opened
in 1956 to provide training for various categories of health personnel
including interns, midwives, nurse-midwives, gramsevekas (women
welfare workers), and sanitary inspectors. It was under the direct
control of the Maharashtra State Government.
The health unit contained a large health museum, offices, class
rooms, and outpatient facilities. It had no arrangements for inpatients,
surgery, or deliveries. In 1961, a fifteen-room hostel for both female
and male interns was built, about a five-minute walk from the health
unit. A mainline railroad connects Palghar with Bombay. The health
unit had three vehicles, a UNICEF school bus and two ambulances,
all of which were used for transporting staff members and trainees,
not patients. Palghar had a telephone and postal facilities.
The Seven Cooperating Medical Colleges
39
'fire health centre staff included a medical officer of health, an
assistant medical officer who was usually a woman, and a number of
paramedical personnel, mostly nurses. During most of the study
period no medical officer was assigned to the centre, and the assistant
medical officer had to officiate in his place.
Internship Programme
Only a fraction of the interns’ time at Palghar was assigned to
specific tasks, totalling perhaps twenty hours per week. Such activities
included the following:
1.
Clinics: Supervised clinical duties averaged eight hours per
week per intern. Preventive clinics totalled another five hours per
week. Monthly clinics included ear, nose and throat, eye, and dental
clinics. Weekly clinics were held for pediatrics and gynecology.
Specialists from Bombay occasionally visited these clinics, but the
Departments of Social and Preventive Medicine of the three medical
colleges made no regular visits. These departments, however, were
involved in running urban health centres to which students were also
rotated.
2. Field Work: Eight sub-centres were associated with the
Palghar health unit. Physicians were scheduled to visit these sub
centres once a week, accompanied by interns, but the visits often
were not made because of vehicle breakdown or other reasons. Home
visits were very rare, possibly one hour in six weeks with the public
health nurse. Some interns did field work with auxiliary personnel as
part of special research projects, totalling possibly four hours a week.
3. Educational Activities: The medical officer gave between
one and a half and two hours of teaching lectures per week. In
addition, the interns spent about two hours a week in formal health
educational sessions.
Christian Medical College, Vellore
The Christian Medical College at Vellore was founded as a
licentiate medical school for women, and was later upgraded to offer
the M.B.B.S. degree. At the time of the study, the student body was
half female and half male. A Department of Social and Preventive
The Seven Cooperating Medical Colleges
Doctors for the Villages
40
Medicine (now called the Department of Community Medicine) was
begun in 1954. Most of the support came from cooperating missions.
A majority of students came from an urban background, but thirty
jjercent came from rural areas. The educational level of the fathers of
Vellore students ranked highest among tire seven medical colleges.
Twenty-one percent of fathers were doctors and another nineteen
percent were in government service. Vellore students tended to come
from average income families, most with a monthly income of less than
Rs.1000. Seventy-eight percent of the students were Christian; fiftynine percent were under contract to various missions to render service
in return for educational expenses.
Rural Internship
The rural health centre and hospital were located on the edge of
the Vellore College campus, four miles from tire main teaching hospital
in the centre of the city. A good road connected the health centre with
tire city and the main hospital; ambulance, jeep, and public bus service
were available. The facilities included examining cubicles for out
patients, pharmacy, laboratory, waiting room, seminar rooms, and
offices. A separate little hospital near the main building housed
inpatients and had a surgical unit where innovations were experimented
with to develop and adapt simple technology appropriate for rural
settings. A small maternity hospital had also been built nearby. In
the same area there was an outstanding experimental facility for the
surgical care and rehabilitation of leprosy patients. Living quarters
existed for the medical officer in charge, the lady medical officer, and
tire public health nursing supervisor. Interns at the health centre lived
in their own hostel nearby.
Professional staff included two full-time physicians (one male, one
female), one part-time physician, several nurses, and a variety of other
paramedical personnel. The faculty of tire Department of Social and
Preventive Medicine were involved in both service and teaching. Var
ious clinicians—including surgeons, pediatricians, and internists—took
a keen interest in the rural programme. All of this contributed to a
great degree of activity in the rural hospital.
Internship Programme
The rural internship lasted twelve weeks, and was divided into a
41
six-week rural hospital programme with emphasis on clinical work and
six weeks devoted to public health activities and research.
1. Rural Hospital Programme: For six weeks, interns worked
with both outpatients and inpatients at the rural hospital. General
medical clinics were held in the mornings. In the afternoons, interns
assisted in maternal and child health and leprosy clinics. They were
encouraged to follow-up cases they had seen previously, and were
required to do all the laboratory investigations for their patients. They
also assisted in the hospital pharmacy and treatment room and gave
health instruction to both inpatients and outpatients. Finally, each
intern went on six consecutive visits with one of the mobile dispensary
vans which toured neighbouring villages.
2. Community Programme: For the other six weeks of the
rural posting, interns could choose to work at one of the following
facilities: the Leprosy Research Sanitorium at Karagiri; the Student/
Staff Health Service; or a field research programme of the department.
The research projects included field surveys of general health status;
epidemiology of particular conditions, especially nutrition; combined
laboratory-field studies; and socio-economic and sociological studies.
During this assignment each intern prepared a paper on a public health
subject which was presented at a department staff meeting.
Medical College, Trivandrum
Trivandrum Medical College opened in 1951 in the capital of
Kerala as a state-supported medical college under the State Ministry of
Health. At the time of the study, the students were predominantly
from poor families and rural areas. Almost one-quarter of their fathers
worked in agriculture, although more than half had a college education.
One-third of the students were Christian but the majority were Hindu.
Thirty-eight percent were women.
Rural Internship
When the project started, the teaching health centre was located
at Cheruvickal near the campus, but in 1964, a new health unit was
opened at Pangappara, about five miles from the medical college on a
national highway. Consultation rooms, a laboratory, pharmacy, record
room (with an up-to-date record keeping system), lecture room, clinic
42
Doctors for the Villages
demonstration room, and offices made up the new centre. During the
study, facilities for inpatients, a library, and living quarters for the
staff were being planned. The jeep at the centre was used only for
transporting staff and interns between the health centre and the
medical college where they lived. No telephone was available. The
staff of the main health centre consisted of two full-time doctors and
a large complement of paramedical personnel.
Internship Programme
The two-month internship programme focussed largely on clinical
work.
1. Clinical Work: Interns at the health centre were engaged in
the following activities: supervised clinical work (seventy-five percent
of their time), preventive clinics (twenty percent), and home or sub
centre visits with the lady medical officer (five percent). Outpatient
services centred on general medical care clinics, and prenatal, pediatric
and family planning services provided in maternal and child health
clinics. They took turns in doing the laboratory work for the centre.
They also visited sub-centres on a weekly schedule.
2. Field Work: Research projects and field investigations were
carried out by the Department of Social and Preventive Medicine.
Interns were not involved in the general data collection, which was
done by third and fourth year students. Rather, the interns were
responsible for tire detection and treatment of illnesses during surveys
and referral of serious cases to hospitals.
3. Educational Activities. Some interns spent some time in
reading, but this was done on their own time in the hostel. No
consistent pattern of didactic teaching was maintained, although
intermittently some faculty members conducted intensive special
programmes.
The Seven Cooperating Medical Colleges
43
4
Social and Demographic
Characteristics of Interns
During the three years covered by the definitive study (July 1963
through 1966) a total of 1,480 interns from the seven cooperating
medical colleges served in the rural internships being studied. For a
variety of reasons, a few interns who filled in the "before" forms were
not available to fill in the "after" forms, and vice versa, so the numbers
were not always precisely the same, but these variations were minor.
The medical colleges varied markedly in tire size of classes.
During the three years the study included: 333 interns at Nagpur;
282 at Trivandrum; 255 at Bombay; 223 at Lucknow; 130 at Vellore;
131 at the All India Institute of Medical Sciences in Delhi; and 126 at
Ludhiana. The study group was made up of 964 men and 516 women.
Table 4.1 gives the percentage distributions of interns according to sex
and age at the seven medical colleges. Vellore had the highest percent
age of female interns, Delhi, Nagpur and Lucknow had the lowest.
The age group 23-24 years old included fifty-one percent of all
the interns (Table 4.1). This relatively low age for medical graduates
compared with many other countries is due to the Indian pattern of a
concentrated eleven to twelve years of education followed immediately
by admission to the five or sLx years of medical school education.
Female interns were somewhat younger than males.
Table 4.2 gives the distribution of interns by residential back
ground. In this study, rural background has been defined as residence
in a village or small town for at least ten years; urban background was
defined as residence in a city for the entire lifetime; and mixed
background was any remaining combination. Interns from Bombay
were mostly from an urban background (seventy-two percent), as were
those from Lucknow and Delhi (sixty-eight and sixty percent respect
ively). The highest proportion of interns with rural background was at
Social and Demographic Characteristics of Interns
45
Trivandrum (seventy-eight percent). Comparatively fewer interns had
a mixed background, the most being twenty-three percent at LudhianaTable 4.3 gives the percentage distribution of interns according to
the level of education of their parents. In general, interns’ fathers were
well educated, sixty percent having a college education and another
twenty-nine percent with secondary school education. Interns from
Delhi, Vellore, and Ludhiana had the highest percentage of fathers with
a college education
(eighty-one, seventy-seven and seventy-one
respectively); whereas those from Nagpur had the lowest (forty-nine
percent). The educational level of mothers was lower than that of
fathers. Only fourteen percent had a college education, although forty
percent had a secondary education. Mothers of interns from Vellore
were the most highly educated; forty-one percent had graduate
degrees. Ludhiana ranked second with twenty-five percent. These
high figures probably reflect the preference given to applicants whose
mothers had been educated at these two colleges which had originally
been women’s colleges. Consistent with the generally high level of
education in Kerala, sixty percent of the mothers at Trivandrum had
secondary education.
Employment of the interns’ fathers (or guardians) is given in
Table 4.4. Seven categories were included: medicine, agriculture,
government service, business, education, no employment, and other.
Only seven percent of the fathers were unemployed. The fathers were
fairly evenly distributed among the other six categories, with the
highest overall figures being eighteen percent for both government
service and business. The highest percentage of fathers in medicine
was at Vellore (Twenty-one percent).
In Table 4.5, the distribution of interns according to income of
fathers (or guardians) showed very few in the top category earning
over Rs.3000 per month, the highest being twelve percent in Bombay.
The next highest category (Rs. 1001/3000 per month) included
thirty-two percent of fathers from Delhi and thirty-one percent from
Bombay. Most fathers had the relatively low income level of
Rs. 200/500 per month; forty-one percent of fathers from Trivandrum,
thirty-nine percent from Lucknow, thirty-eight percent from Nagpur,
and thirty-three percent from Vellore. Another thirty percent of
fathers from Trivandrum and twenty-seven percent from Nagpur
fell into the lowest category of less than Rs. 200 per month.
Table 4.6 gives the percentage distribution of rural interns by
Doctors for the Villages
religion. The predominant religion was Hindu (seventy-three percent),
followed by Christian (eighteen percent), with smaller proportions of
Sikhs, Moslems and others.
Frequency of .village visits by interns during their medical course
but before their rural internship was recorded in four categories:
regularly, occasionally, once or twice, and never. Thirty-three percent
of tire interns from Bombay had never visited villages during their
medical course, a much higher percentage than at any other centre.
The greatest amount of visiting was recorded at Ludhiana, Trivandrum,
and Vellore (all more than thirty percent regularly and sixty percent
occasionally). Some of this visiting, of course, was to homes of
relatives, but most of it was during field visits in undergraduate
courses conducted by the departments of social and preventive
medicine at these medical colleges.
At Trivandrum, one hundred percent of the interns were under
contract to tire government to serve in the state health system after
medical education. Fifty-nine percent of Vellore interns and sixteen
percent of Ludhiana interns had service contracts to work in a mission
hospital after completion of their medical education in exchange for
financial support for their education.
Social and Demographic Characteristics of Interns
Table 4.1
46
47
Table 4.2
Percentage Distribution of Rural Interns in the Seven Cooperating Colleges
According to Residential Background
Bombay
(N-255)
Delhi
(N-131)
Lucknow
(N-223)
Ludhiana
(N-126)
Nagpur
(N-333)
Trivandrum
(N-282)
Vellore
(N-130)
All Colleges
(N-1480)
Rural
10
20
21
30
36
78
30
35
Urban
72
60
68
47
49
12
66
50
Mixed
18
20
11
23
16
10
15
16
Residential
Background
b
o
o
"o’
CX)
s
Percentage Distribution of Rural Interns in Seven Cooperating Medical Colleges
According to Educational Level of Mother and Father
Educational
Level of
Parent
Bombay
Delhi
Lucknow
Ludhiana
Nagpur
Trivandrum
Vellore
All Colleges
Mother Father
Mother Father
Mother Father
Mother Father
Mother Father
Mother Father
Mother Father
Mother Father
Not literate,
can just read
and write,
or primary
45
11
44
7
63
13
42
7
63
21
29
8
10
2
46
11
Secondary
School
42
36
42
12
29
26
33
22
29
30
60
37
48
21
40
29
College or
Higher
13
53
14
81
8
61
26
71
8
49
11
55
41
76
14
60
Social and Demographic Characteristics of Interns
Table 4.3
Tabic 4.4
Percentage Distribution of Rural Interns in Seven Cooperating Medical Colleges
By Type of Employment of Father (or Guardian)
Employment
of
Father
(or Guardian)
Bombay
Delhi
Lucknow
Ludhiana
Nagpur
Trivandrum
Vellore
Al! Colleges
(N-265)
(N-131)
(N-223)
(N-l26)
(N-333)
(N-282)
(N-l 30)
(N-l < 80)
17
19
14
18
15
6
21
15
12
Apiculture
1
5
11
8
22
23
1
Government
Service
11
29
21
21
14
19
19
18
Busineu
33
17
25
11
17
8
8
18
Education
4
5
6
6
12
20
8
10
10
No Employment
5
6
6
7
5
11
7
Other
29
20
17
29
15
14
32
20
100
100
100
100
100
100
100
100
Total
Percentage Distribution of Rural Interns in the Seven Cooperating Medical Colleges
By Monthly Income of Father (or Guardian)
Father’s
(or Guardian’s) Bombay
Monthly Income (N-255)
Delhi
Lucknow
Ludhiana
Nagpur
Trivandrum
Vellore
All Colleges
(N-131)
(N-223)
(N-126)
(N-333)
(N-282)
(N-l 30)
(N-l 430)
Up to Rs. 200
1
4
15
17
27
30
13
18
Rs. 201 - 500
19
29
39
25
38
41
33
33
Rs. 501 -1000
31
30
32
31
24
21
Rs. 1001 - 3000
31
32
13
18
9
7
17
17
Over Rs. 3000
12
5
1
9
2
1
6
4
Total
100
100
100
100
100
100
100
100
COMMUN(rY H
V M8in, /6Jock
Koramfcngr||a
e«ngalora-560034
Indi.
/
28
Social and Demographic Characteristics of Interns
Table 4.5
Doctors for the Villages
LO
Medicine
Al! Colleges
(N I480)
co
Vellore
(N-130)
t"
Trivandrum
(N-282)
GJ
CD
100
CO
CO
04
CO
100
t"
04
,
t00
XT
04
io
04
Hindu
XT
04
rH
T-4
Total
co
Other
O
CO
100
r-H
Muslim
O
Sikh
O
100
O
CO
2
rH
9
rH
8
LO
37
rH
CO
Christian
(N-220
(NJ 31)
.CO
44
(NJ 2 0
(N-255)
Ludhiana
Lucknow
Delhi
Bombay
Table 4.6
04
001
CO
c
o
1
CO
001
I2
04
'd'
00 1
— 'o
00
100
Doctors for the Villages
52
5
Career Choice
To understand the attitudes of recent medical graduates toward rural
service, it is first necessary to appraise their career preferences in
general. Efforts to overcome their reluctance to serve in villages must
rest on a better understanding of their attitudes toward alternative
choices available to them.
Four sets of questions provided ranking of responses: preferences
for various medical specialties including public health practice and
academic careers in preventive. and social medicine; preferences for
various types of professional work with implied payment arrangements
such as service in rural health centres or private practice; statements of
their personal response to twelve motivating factors in career choice;
and an estimate of their anticipated monthly income ten years after
graduation from medical college.
Specialty Preferences
During the first year of the study, an additional question was
included which asked for the intern’s estimate of the prestige that
the general public attached to thirteen different specialties. More
than 230 interns answered this question, and the pattern that emerged
was so clear that the question was not considered worth exploring
further. Surgery was rated highest in prestige. Social and preventive
medicine and public health were rated very low in prestige. Similar
patterns have been found in other studies around the world.
In scoring their own personal preferences for various specialties
(Fig. 5.1), the interns gave responses which essentially duplicated their
54
Doctors for the Villages
estimates of public prestige. Personal preference was highest for
surgery, followed by pediatrics, general practice, and internal medicine.
Preclinical sciences, social and preventive medicine, and public health
was lowest in their ranking of preferences.
Preferences for particular medical specialties were cross-tabulated
against the amount of interest expressed in rural service. We combined
the greatly interested and moderately interested groups (twenty-eight
percent of tire respondents) and tabulated separately those slightly
interested (thirty-four percent) and not interested
(thirty-eight
percent). As expected, those interns with most interest in primary
health centres also showed more interest in social and preventive
medicine and in public health than other groups (Fig. 5.2). They
ranked general practice and pediatrics as their first two choices, and
their interest in surgery was just as high as in the two groups with less
interest in rural services. After the rural experience, their interest in
public health and social and preventive medicine remained essentially
unchanged, whereas tire other two groups showed a lower level of
interest.
When tire interns’ backgrounds were cross-tabulated against their
interest in particular specialties (Fig. 5.3), clear differences emerged
which were related to rural exposure. Those with a rural background
showed greater interest in general practice and public health than
interns who had a mixed or urban background. There was less
difference in interest in tire teaching of preventive and social medicine
which may be related to the observation that interns with a rural
background were less interested in teaching generally.
Activity Preferences
Analysis of interest in types of professional service showed that
most interns strongly preferred private practice in a medical specialty.
In descending order of preference then were research, work in
government hospitals, and general private practice in urban areas. Not
surprisingly, the lowest level of preference was for administrative
positions in health and hospital services and in primary health centre
work in rural areas.
Interest in rural health centres was cross-tabulated against the
other types of service listed in this question (Fig. 5.4). Some sharp
differences emerged. Those not interested and those only slightly
interested in primary health centre work showed a clear preference for
Career Choice
55
private practice in a specialty. Those with greater interest in rural work
were distinctly less interested in both private practice and in teaching.
Those with greater interest in rural work also showed considerably
more interest in general private practice in rural areas, in government
hospital work, and in administration.
Comparisons between personal background and professional
interest (Fig. 5.5) showed some clear and important differences.
Those who came from a rural background had considerably more
interest in primary health centre service than did those who came from
an urban background. Specialty private practice was ranked highest
by interns from urban and mixed backgrounds. Those from rural
backgrounds, however, showed as much interest in urban general
practice as in specialty private practice and even more interest in
work in a government hospital. Also, interns from a rural background
showed greater interest in general private practice in rural areas than
those from a mixed or urban background.
Activity preferences were greatly influenced by sex (Fig. 5.6);
female respondents were found to be more interested in service in
hospitals, both private and government, than male respondents. The
most marked differences were the greater interest in teaching and in
general private practice (urban) recorded by male interns. Of most
importance to this study was the finding that men also showed more
interest in primary health centre work.
Of particular interest, of course, is the question of whether there
was any relationship between interest in rural service and the type of
medical college attended. Since we had agreed with the colleges that
we would not separately identify their data in this presentation, we
have grouped them according to the proportion of urban students so
as to give an indication of trends. Table 4.2 showed that Bombay,
Delhi and Lucknow had more than sixty percent urban students;
Ludhiana, Nagpur, and Vellore had between forty-seven and fifty-five
percent urban students; and Trivandrum had twelve percent urban
students. A simple calculation of the percentage of students indicating
moderate or great interest in rural service showed the following
percentages: the most urban colleges had eight, fifteen, and twenty-one
percent interest in rural service; the percentages in moderately urban
colleges were nineteen, twenty-five and thirty-five; and in the rural
college fifty-four percent of students were moderately or greatly
interested in rural service.
Cai cer Cnoice
56
Doctors for the Villages
.Motivating Factors
Interns were asked to score their agreement with twelve factors
considered to be potentially important in determining career choice.
Intellectual satisfaction and national needs were ranked highest (Fig.
5.7). Specified hours of work and nearness to home were lowest. On
the whole, high rankings were given to all items: five of the mean
values were above or close to 2 (moderately important on the scale)
and none were below 1 (slightly important). Even though nearness to
home ranked twelfth, the mean value of 1.28 indicates that it was still
more than slightly important. For policy makers, it is worth pointing
out that the item that ranked first (intellectual satisfaction) had a
mean value after the internship of 2.51, with sixty-one percent
considering tins of great importance, thirty-one percent moderately
important, five percent slightly important, and only three percent
saying this was of no importance.
When factors in career choice were cross-tabulated against the
degree of interest in primary health centre work, intellectual
satisfaction was ranked first by all three sub-groups. Figure 5.8 shows
that prestige was of less concern to those interested in rural work,
while national needs and humanitarian motivation were considered
somewhat more important than for other groups. All groups gave
equal importance to financial remuneration and job opportunity.
In Figure 5.9, the answers of male and female interns are
compared in the scores assigned to these motivating factors. Women
were more concerned with opinions of family members, nearness to
home, specified hours of work, and leisure opportunities than were the
men. Prestige was of less concern to women than to men, although it
still ranked higher than the other four items mentioned, except for
opinions of family members.
Anticipated Income
The interns were asked to estimate the monthly income they
expected to be earning in ten years; it was thought that desire for
material gain might be related to expressions of interest in rural service.
They were given six choices, ranging from less than Rs.500 per month
to more than Rs.3000 per month. At the start of the rural posting
forty-eight percent of the interns expected to earn more than Rs. 1500
per month after ten years; after the internship this rose to fifty-four
percent. When interest in primary health centre work was compared
with expected income (Fig. 5.10), an inverse relationship was found
between income expected and degree of interest in primary health
centre work. A realistic acceptance of future income was indicated, in
that those highly interested in primary health centre work had lower
financial expectations than the other two groups.
Male interns expected to earn a higher income than did female
interns. Expectations increased after the internship, although more so
for women.
Finally, we compared anticipated income with the
reported income of the intem’s father (Fig. 5.11). Interns from richer
families had higher expectations than those from poorer families. In
fact, the expectations of the rich were more than double those of
interns from poor families. After the internship, the greatest increase
in expectations was registered by those respondents whose fathers made
less than Rs.1000 per month.
Fig. 5.2
Interns’ Interest in Selected Specialties Compared With Interest in Rural Service
(Before and After Internship)
SPECIALTIES
Before
After (Rural Internship)
N = None
S ■ Slight
G = Great or Moderate
Fig. 5.3
,Inter
. ns Interest
.
. in
. «>'
„ '>,■>•—
, ----opeciai
ties
Compared
With Residential Background
of Intern
1—--------------- 1---------------------------------“------------------(Before and After Internship)
Doctors for the Villages
Fig. 5.4
Interns Interest in Selected Professional Activities Compared With Interest in Rural Sendee
Mean Interest in Professional Activities
(After Internship)
Government
Hospital
(Private)
Specialty
N
N
Private Practice
(Rural)
Administration
Teaching
0
S
G
S G
N = None
S = Slight
G = Great or Moderate
ro
Fig. 5.5
Interns’ Interest in Selected Professional Activities
Compared With Residential Background of Interns
(After Internship)
(Private)
Specialty
Government
Hospital
Private Practice
(Urban)
Research
Primary Health
Centre
Private Practice
(Rural)
R
Doctors for the Villages
U M
;
Career Choice
Fig. 5.6
Interns Interest in Selected Professional Activities by Sex
(After Internship)
Teaching
Male
Female
if.
o
e
Fig. 5.8
Importance to Interns of Factors in Career Choice Compared With Interest in Rural Service
(Before and After Internship)
MOTIVATING FACTORS
Interest in Rural Service
Before LIB Afler (Rural Internship)
N ■= None
S - Slight
G = Great or Moderate
66
Doctors for the Villages
Career Choice
67
Fig. 5.10
Expected Monthly Income in Rupees
Importance to Interns of Factors in Career Choice by Sex
Interns Expectations of Monthly Income in Ten Years
Compared With Interest in Rural Service
(Before and After Internship)
Before
After
(Rural Internship)
Doctors for the Villages
68
Fig. 5.11
Interns’ Expectations of Monthly Income in Ten Years
Compared With Father’s Monthly Income
(Before and After Internship)
6
Attitudes of Interns
to Primary Health Centres
Expected Monthly
Income
in Rupees
and Villagers
By identifying interns’ attitudes towards health centre working
conditions, programmes, living conditions, and villagers in general, it
should be possible to determine those changes that will make rural
service more attractive to young doctors. Their perceptions of
problems will also help identify measures needed to improve services.
There are, of course, some rural conditions which cannot be changed
and doctors will have to learn to adjust to them, but better education
can help this adjustment.
Data were elicited from interns using questionnaires and the
Rural Thematic Apperception Test. Information was gathered on:
—
conditions under which an intern would be willing to serve
in a primary health centre;
—
factors which may influence favourably or unfavourably the
way an intern feels about working in a primary health centre;
the Interns’ opinions about the activities which they think a
health centre physician should perform;
the interns’ attitudes towards village people; and
some subtle attitudinal variables relating to underlying
orientation and motivation for rural service.
—
Before
n
—
—
After (Rural Internship)
Conditions Under Which Rural Service Would Be Acceptable
In
the questionnaire, we listed eleven conditions, ranging
progressively from very negative to positive responses that interns might.
70
Doctors for the Villages
have to rural work. Interns were asked to score on a four-point scale
their level of agreement with each condition.
Only seven percent agreed with the condition that they would
leave medical practice rather than work in rural areas (Fig. 6.1). At
tire other extreme, six percent agreed that they would sacrifice both
professional and personal considerations in order to work in rural areas.
The item with which most interns agreed was that they would work in
rural areas if both living conditions and professional standards were
improved. When personal and professional conditions were separated,
more importance was attached to good professional standards (ranked
second) than to improvement of living conditions (ranked sixth). The
item stating “/ would work under present conditions if I knew I would
not be stuck in the village for life, ” elicited an interestingly positive
response, ranking third among the answers. The proposition that they
would accept rural service only if it were legally required ranked
fourth. The mean values of most items were below the midpoint of the
scale, indicating that the interns disagreed more than they agreed with
most conditions.
Cross-tabulation of responses to conditions for rural service against
tire degree of interest in rural service (Fig. 6.2) showed that all groups
ranked improvement of both professional and living arrangements first.
Those interns with greater interest in rural work gave more importance
to the single objective of improving professional standards thandid the
other groups. They also placed somewhat more importance on
improved living conditions than did those who were not seriously
considering village service. Those who indicated slight interest in
working in rural areas agreed more strongly than the others with the
condition that they would undertake village work if they were not
then to be stuck in a village for life.
As might be predicted, those who were more interested in working
in rural areas were more inclined to sacrifice personal and professional
considerations, whereas those not interested in working in rural areas
were more inclined to say they would leave medical practice rather
than serve in rural areas. The only before and after shifts that were
notable were that those interns not interested in village service were
more inclined, as a result of their internship experience, to leave
medical practice and less inclined to accept improved professional and
living standards (Fig. 6.3).
Attitudes of Interns to Primary Health Centres and Villagers
71
Students from the most urban colleges are least likely to serve in
rural areas. As pointed out in Chapter 3, we are not presenting specific
data on individual colleges, but have made comparisons based on the
following groupings: Bombay, Delhi, and Lucknow had more than
sixty percent urban students; Ludhiana, Nagpur and Vellore had
between forty-seven and fifty-five percent urban students; and
Trivandrum had twelve percent urban students. Figure 6.4 shows those
selected items on which there were significant differences between
these three groups of colleges. The proportion of urban students in
these colleges was directly related to the strength of interns’ agreement
to the four items stating that they would leave medical practice rather
than serve in rural areas, serve only under financial or legal compulsion,
if unable to find work elsewhere, or if they could live in a nearby city.
On the other hand, there was an inverse relationship with expression
of willingness to put up with poor living conditions if professional
standards were improved.
Factors Favourably Influencing Attitudes to Rural Service
Interns were asked to score, on a four-point scale, twelve factors
which might favourably influence their decisions about work in rural
areas. Most items received a high rating, with the mean value of the
lowest items still ranging above the midpoint of the scale. Five items
which were considered especially important were: opportunities to
deliver direct medical care, service to needy people, combining
preventive and curative services, independent responsibility, and
helping to meet national needs (Fig. 6.5). It is interesting that
administrative control over technical work find personnel received a
very low ranking, as did a high position in local society. The chance to
express spiritual and humanitarian motivation and being able to make
one’s own schedule ranked almost as low.
When the importance of these favourable factors was cross
tabulated against interest in rural health service (Fig. 6.6), clear
differences were seen. Those greatly interested in rural health gave
more importance to chances to combine preventive and curative
services, helping to meet national needs, studying the community as a
whole, organizing health services, and exercising administrative control.
This is consistent with earlier responses showing that, in general, those
interested in rural health service also responded more favourably to
preventive medicine and public health.
72
Doctors for the Villages
A further item of considerable importance derives from the impact
of the internship experience. For each of these items it can be seen
that there was a clear pattern: those with no interest in rural service
rated preventive activities as being less important after their rural
service than before; those greatly interested recorded no decrease in
their recognition of tire importance of preventive activities; and those
slightly interested had an intermediate drop.
Factors Unfavourably Influencing Attitudes to Rural Service
Defining the factors blocking recruitment to village service was
among tire most important objectives of this research project. In fact,
as the hypotheses for this study were being developed, as described in
Chapter 2, it was evident that almost all of the hypotheses could most
readily
be stated rather simply as factors which unfavourably
influenced decisions about choosing rural work. It is remarkable how
many good reasons doctors can find for not wanting to work in villages.
The factors listed in the questionnaire are too numerous to
reproduce here (see Appendix). However, they must all be taken into
account, both by medical educators trying to change orientation and
especially by administrators who must realistically face their obligation
of making health centres decent places for doctors to work. In Figure
6.7, unfavourable factors are separated into professional and personal
classifications, but in the question as it was administered the items
were randomly mixed.
Of the first five items in overall ranking, four deal with profes
sional considerations. This is in congruence with many findings in
Ulis study showing that professional considerations were more
important than personal desires in the choices being made by these
recent medical graduates.
The one personal item that stands out and is, in fact, ranked
second overall among tire twenty-seven items, was lack of educational
facilities for children. This response strongly supports a general
recommendation that the most reasonable system would be to have
doctors rotate through a period of rural service shortly after graduation
before educational facilities for children would become a major issue.
For those choosing rural health as a lifetime career, however, it would
be crucially important to provide children with educational opportun
ities at least equal to what their parents had received.
With great consistency, the most important deterrent to effective
Attitudes of Interns to Primary Health Centres and Villagers
73
rural work was identified as inadequate provision of drugs and supplies
and insufficient equipment. These are legitimate and remediable
concerns. The Government could do more about attracting doctors to
rural service by supplying these elementary needs than by any other
measure identified. The excuse most often given for providing minimal
budgetary allocations to keep inventories of drugs and supplies low
is the general concern that these expendable items will be sold for
profit by employees. As a result, health centres all over the country
share a drastic and chronic shortage of the most elementary necessities.
It is demonstrably poor economics to put large investments into
personnel and facilities and then to cancel out any possibility of
effective work by not providing the relatively smaller investment for
drugs and supplies. It would make much more sense in economic terms
to accept even a fifty percent loss in drug costs, if that would make the
total health centre programme effective. Or, a more rational policy
might be to make patients pay for all but the most basic drugs rather
than trying to provide them free to anyone except the truly indigent.
This would automatically introduce financial controls. Perhaps the best
way of getting effective control of drug supplies and costs is to actively
involve the formation of a local health committee and to encourage
them to supervise community financing.
Rated next in importance is an interesting group of factors: lack
of opportunity for postgraduate education; lack of opportunity for
professional advancement; and poor access to libraries and reference
materials. These, too, are amenable to effective solution at relatively
low cost. They would require a combination of active involvement of
medical colleges and consistent attention by the Government. Pro
spects of professional advancement and postgraduate education, for
instance, could be directly linked to requirements that each doctor
must complete a specified period of village service. Similarly, it should
be possible to arrange for regular circulation of relevant reading
material and reference sources to primary health centre doctors.
Trying to see too many patients in a crowded clinic has been
identified repeatedly by experts in health administration as perhaps
the greatest operational block to effective reorganization of health
centres and to quality care. Curiously, however, the interns ranked
it lowest in importance. This may reflect their having already become
accustomed to heavy case loads in outpatient departments of the
hospitals where they trained. The only remedy for this serious
74
Doctors for the Villages
problem is to turn routine simple medical care over to auxiliaries as
discussed in detail in Chapter 8.
Under personal factors, the most evident considerations, next to
education of children, are concern about lack of transportation to and
communication with urban areas. Ranking eighth below the profes
sional and personal items mentioned above, is the usually exaggerated
issue of not enough pay.
The responses to unfavourable professional considerations were
cross-tabulated against interest in rural health service. Differences were
minor, since there was general unanimity on these issues (Fig. 6.8).
The greatest differences were in responses about the lack of opportun
ity for post-graduate education and for professional advancement;
those with no interest in rural work showed more concern about these
points. Cross-tabulation of personal considerations against the amount
of interest in rural health service also showed few differences (Fig.
6.9). As would be expected, those not interested in rural work were a
little more concerned about not enough pay and about the problems of
living in a village.
Responses to unfavourable factors were then compared according
to the intern’s background (Fig. 6.10). In almost all instances, interns
from an urban background gave a more unfavourable ranking to items
than did those from a rural background, particularly in their general
attitude toward living in a village. Urban and rural interns showed
almost equal concern about the lack of suitable housing.
A comparison of male and female interns’ opinions about
unfavourable factors (Fig. 6.11) showed that there was little dis
agreement at the two extremes, top and bottom, of the rank ordering:
inadequate drugs and supplies, and too many patients. Some other
items, however, showed considerable variation. Female interns were
less concerned about supervision by non-medical officials, political
interference, and pay. But they realistically showed considerably more
concern than did male interns about objections of spouse, and a little
more concern about personal safety.
Functions Considered Appropriate for the Health Centre Physician
On a list of functions normally carried out in a primary health
centre, interns were asked to check whether each item should never,
occasionally, or routinely be performed by the primary health centre
Attitudes of Interns to Primary Health Centres and Villagers
75
physician himself. Figure 6.12 shows that curative functions, such as
caring for all inpatients and attending to minor surgery and simple
fractures, were ranked highest, with almost general unanimity that
they should be done routinely.
By contrast, interns generally disagreed with the proposal that the
health centre doctor should see only seriously ill patients and arrange
for a nurse or auxiliary to care for the more common and less serious
illnesses. These responses are consistent with the interns’ feelings,
referred to earlier, that too many patients is not a serious problem.
Changing the rigid attitude of the medical profession that medical
care should be the exclusive prerogative of doctors is
crucially
necessary if rural health services are to be rationalized. Operations
research on health centre activities suggests that nothing can be done
about improving health centre services until the medical care load is
more reasonably distributed. In all countries, including the long
established feldsher system of Russia and the new physician assistant
programmes in the United States, there is growing recognition that
many medical care functions can safely be delegated to personnel other
than fully qualified doctors. These interns can scarcely be blamed for
not having spontaneously recognized the need to distribute the medical
care load, since it is deeply ingrained in tire training and professional
etluc imparted in medical schools. Basic policy changes have to be
made in role allocations in the health team, and a whole new pattern
of comprehensive care developed before effective reorientation of
training programmes will be possible.
Preventive functions were generally scored as less important
responsibilities for the primary health centre doctor than curative
functions. In differentiating among preventive functions, interns
-Tanked highest the control of outbreaks of communicable disease and
running maternal and child health and family planning clinics. They
were not particularly impressed with the necessity for doctors to
perform such functions as promoting latrines, water pumps, and
smokeless chulas (kitchen fireplaces with a chimney to carry off
smoke), but they did seem to accept the need for holding staff
meetings and doing routine office work and writing reports.
The opinions of interns about the role of primary health centre
doctors were cross-tabulated against interest in rural health (Fig. 6.13).
Interns who expressed the greatest interest in working in rural areas also
accorded more importance to preventive functions, such as working
76
Doctors for the Villages
with auxiliary staff in the field, checking work records of auxiliary
staff, conducting mass health education meetings, and studying the
social structure and factions in villages. This suggests, in fact, that
these individuals may be more prepared to exercise team leadership
and supervision responsibilities themselves, rather than merely con
centrating on performing curative functions.
Attitudes Toward Villagers
If interns do not like villagers, it is unlikely that they will be
spontaneously attracted to serving them. While it is difficult to elicit
subtle distinctions in likes and dislikes, some indications can be
obtained by direct questioning. Questions which have already been
discussed have recorded varying resistance to living in a village,
particularly if it meant living there for life; a concern about lack of
educational facilities for children; lack of transportation to and
communication with urban areas; lack of work facilities to maintain
professional standards; and career opportunities.
As a more indirect approach to finding out about the attitudes of
interns to villagers, the paired comparison method of questionnaire
construction was used. A list was developed of a series of opinions
traits and personality characteristics. On a four-point scale the interns
then indicated their generalized opinion about where villagers as a
group tend to fall between each pair of characteristics (Fig. 6.14).
In general, interns considered villagers to be religious, honest, friendly
and cheerful. On the more negative side they were also considered
superstitious, poorly informed, poorly fed, dirty, and gossipy. Answers
given before and after the internship were not significantly different,
despite the presumably greater opportunity to get to know villagers
during the internship.
These attitudes were then cross-tabulated with interest in rural
health work. Those with more interest in rural health work tended to
have more favourable attitudes toward villagers than did those with
slight or no interest in rural health work (Fig. 6.15). For instance,
those interns with more interest in rural work were more likely to
consider villagers to be friendly, cooperative, optimistic, wise, trusting
and clean titan those interns uninterested in village work.
A separate analysis was done comparing attitudes to villagers with
tire proportion of urban students in the various medical colleges. The
Attitudes of Interns to Primary Health Centres and Villagers
77
three colleges with more than sixty percent urban students were
compared with the three colleges with approximately fifty percent
urban students and the one college with twelve percent urban students.
In Figure 6.16, those items on which significant differences emerged
are shown. The more urban the student body, the more the interns
tend to think of villagers as being dirty, unhealthy, unfriendly,
uncooperative, lazy, suspicious, pessimistic, and having a tendency to
malicious gossiping.
Rural Thematic Apperception Test (RTAT)
An even more indirect means of exploring the underlying attitudes
of interns was through a modified Rural Thematic Apperception Test
(RTAT). In this test, the interns were asked to write short stories
about rural situations. Test booklets were prepared with a series of six
pictures showing a person who might have been a doctor in various
types of relationships with village people.
By using a standardized coding manual, the stories were categor
ized according to whether they reflected a particular attitude or
characteristic, such as: enthusiastic idealism (E); favourable attitudes
to villagers (V+); unfavourable attitudes to villagers (V—); interest in
public health (PH); scientific interest (SC); and a doctor being
consulted appropriately (C). A no score result refers to stories which
were so noncommittal that no category of response could be scored for
them and this in itself is an important indication of attitude. It was
possible, of course, to have several scores for a single story.
A number of pictures had been scored in careful pretests so that
we could select two sets of pictures (of six each) that matched each
other in that they elicited similar responses for each test characteristic.
These two sets were administered in an alternating sequence before and
after the internship so that each set was essentially equally distributed
in being given at the beginning and end of the village experience. This
pattern was carefully administered to eliminate as much bias as possible
in the various sets of pictures.
The biggest changes in attitudes to village life following the
internship occurred in the V— category (unfavourable reference to
village life) which sharply decreased. It is to be noted, however, that
this generally unfavourable reaction to villages still received the highest
scores, an indication of the general salience of negative attitudes
78
Doctors for the Villages
(Table 6.1). The greatest decrease in V— occurred in the interns having
a mixed rural and urban background, but much less change was found
in interns from a rural background since they presumably already knew
about village life. Urban interns also seemed to find that villages were
not as bad as they had expected. On the whole, there were also more
V+ scores (favourable references to village life) after the internship
than before. The V+ responses of interns from a rural background
showed a considerable increase;
surprisingly, the pre-internship
responses of rural interns were lower than those of other groups.
Of particular interest were responses coded as “E” and ”EV”
(enthusiastic or idealistic outlook generally and about the future of
villages). Interns with a rural background showed some increase in “E”,
whereas the other groups showed a decrease. Notably, the second
highest scoring occurred in the “PH” category' — that is, a story which
reflected some recognition of or interest in public health problems or
programmes. While the mixed and urban groups showed no change, a
.considerable increase in “PH” scores was recorded for those from a
rural background. The fairly high scores given to “SC” (scientific
interest) show that interns readily brought into their stories comments
about the importance of scientific contributions to village needs. The
major finding relating to interns’ awareness of the need for consultation
was that a marked increase occurred during internship in the frequency
with which this item was mentioned. It is interesting that this
happened whether the intern happened to come from either a rural or
an urban background.
Attitudes of Interns to Primary Health Centres and Villagers
79
Table 6.1
Rural Thematic Apperception Test (RTAT) Showing Interns’ Attitudes
To Village Work By Rural/Urban Background
(Before and After Internship)
Whole Group
Urban
Mixed
Rural
E
Enthusiastic or
Idealistic Outlook
B
A
47
46
49
42
54
46
43
51
EV
Enthusiasm Plus
Favourable Village Ref.
B
A
49
45
54
48
55
46
41
41
B
A
60
68
65
71
69
64
50
65
Unfavourable Reference
to Village
B
A
102
78
104
77
100
64
99
85
PH
Reference to
Public Health
B
A
67
71
68
68
74
74
63
74
Sc
Scientific Medical
Concern for Patients
B
A
65
62
68
61
62
60
64
56
Doctor Consults
Another Med. Authority
B
A
47
57
48
57
37
60
49
56
No Score
B
A
81
82
74
83
74
73
93
85
Total Number
Answering
B
A
867
787
423
379
125
114
319
294
v+
Favourable Reference
to Village
V-
c
Average index recorded as number of times per 100 interns that specified
characteristic was scored according to RTAT Coding Manual.
Doctors for the Villages
80
Attitudes of Interns to Primary Health Centres and Villagers
81
Table 6.2
Interest of Interns in Primary Health Centre Service
(Before and After Internship)
Fig. 6.1
Moderately
or
greatly interested
Not interested
or
slightly interested
Interns’ Agreement With Conditions Under Which
They Would Serve in Primary Health Centres
Conditions:
E
Enthusiastic or
Idealistic Outlook
B
A
46
45
58
53
Ev
Enthusiasm Plus
Favourable Village Reference
B
A
50
44
46
48
Favourable Reference
to Village
B
A
64
71
51
57
VUnfavourable Reference
to Village
B
A
100
77
109
72
PH
Reference to
Public Health
B
A
65
67
74
85
No Score
B
A
81
87
78
75
Total Number
Answering
B
A
600
529
248
246
v+
-
Disagree
Partially
Disagree
Partially
Agree
Agree
Doctors for the Villages
Interns’ Agreement With Selected Conditions Under Which They Would Serve
In Primary Health Centres Compared With Interest in Rural Service
(After Internship)
Fig. 6.2
82
Attitudes of Interns to Primary Health Centres and Villagers
Fig. 6.3
Interns’ Agreement With Selected Conditions
Under Which They Would Serve in Primary Health Centres
Compared With Interest in Rural Health
And Responses Before and After Internship
If professional standards
and living conditions
are improved
Before
After Rural Internship
Never —
would leave
medical practice before
working in rural area
N ■ None
S = Slight
G " Great
83
Doctors for the Villages
84
85
Attitudes of Interns to Primary Health Centres and Villagers
Fig. 6.5
^^5
Interns’ Agreement With Selected Conditions Under Which They Would Serve
in Primary Health Centres According to Type of Medical CoUege
Fig. 6.4
I
„ JP
—Is “cJ
1
Importance to Interns of Factors
Favourably Influencing Service in Primary Health Centres
(After Internship)
Medical care
2.46
Service to needy people
2.36
Preventive and curative services
2.29
Independent responsibility
2.26
Helping meet national needs
2.20
Meeting unpredictable
medical problems
s
]=
1.80
Organize health service
for large group of people
SaHsaKOHHi 1.74
Opportunity to
study community
ISESSSSSSSHHH 1.73
Make own schedule
IsSSSSSSSiSS
I.
—Jp
1.70
Spiritual and
humanitarian motivation
1.56
High position
in village society
1.55
Administrative control
1.41
1------------------ 1------------------ 1------------------1
0
12
3
--------- Mean Degree of Importance----------
Doctors for the Villages
86
Importance to Interns of Selected Factors Favourably Influencing Service
in Primary Health Centres Compared With Interest in Rural Service
(Before and After Internship)
Fig. 6.6
Attitudes of Interns to Primary Health Centres and Villagers
Fig. 6.7
Importance to Interns of Selected Factors
Unfavourably Influencing Service in Primary Health Centres
87
Fig. 6.8
Importance to Interns of Selected Professional Factors Unfavourably Influencing Service
in Primart- Health Centres Compared With Interest in Rural Service
(After Internship)
Inadequate
drug
supplies
Lack of
opportunity
for
professional
advancement
Inadequate
equipment
Lack of
opportunity
for post
graduate
education
N S G
N S G
0
Doctors for the Villages
Poor access
to libraries,
reference &
research
material
Interest in Rural Service
N = None
S = Slight
G = Great
Importance to Interns of Selected Personal Factors Unfavourably Influencing Service
in Primary Health Centres Compared With Interest in Rural Service
(After Internship)
Lack of
transportation
and communica
tion with
urban areas
Unsuitable
housing
_
Not
enough
pay
...
Living
in
village
Mean Degree of Importance
Lack of
educational
facilities
for children
N
N “ None
S - Slight
G “ Great
S
G
Attitudes of Interns to Primary Health Centres and Villagers
Fig. 6.9
00
90
Doctors for the Villages
Fig. 6.10
Importance to Interns of Selected Factors
Unfavourably Influencing Service in Primary Health Centres
Compared With Residential Background (After Internship)
Lack of Educational
Facilities for Children
l__________________________12.52
2.33
Lack of Opportunity
for Postgraduate Education
I
Not Enough Pay
1______________________ 12.14
Rlfiff'jtiKiMryi 'C-ir* 2.00
Unsuitable Housing
1_____________________ I 2.04
12.03
Lack of Variety
in Clinical Work
Lack of Social
and Recreational Facilities
Health Hazards for Family
Objections of Spouse
_________________1 2.37
9 n7
1 J.83
1.65
L____________
I?-
[_________________ 11.79
.'^49 1.64
1___________ 1 1.79
iSH^^^l.62
I_____________—J 1.60
t.28
Living in Village
1__
_____ 11.46
RSiitfS .93
Fear for Personal Safety
1_____________ 11.28
fgEggjga i no
Too Few Patients
1___________ 1/ 16
i^WI.9/
Background
(____ 1 urban
M rural
1--------------- 1--------------- f--------------- 1
0
12
3
---- Mean Degree of ’I mportance-----
Attitudes of Interns to Primary Health Centres and Villagers
91
92
Doctors for the Villages
Fig. 6.12
Interns* Opinions About Whether Primary Health Centre Physician
Should Himself Perform Selected Functions
(After Internship)
93
Attitudes of Interns to Primary Health Centres and Villagers
Fig. 6.13
Interns* Opinions About Whether Primary Health Centre Physician
Should Himself Perform Selected Functions
Compared With Interest in Rural Services (After Internship)
CURATIVE FUNCTIONS
Caring for all patients
.
1.86
Minor surgery and simple fractures
1.70
Seeing all patients
i.62
Seeing only very ill patients,
leaving rest for nurse
Promoting latrines, pumps,
smokeless chulas, etc.
by personal visits
r~~I-**
Y777777A.M
i.02
Checking work records
of auxiliary staff
I
I 1.04
7777777777 i.26
ExSESSSliB i a?.
.59
Working with auxiliary staff
in field at least once a week
PREVENTIVE FUNCTIONS
I
I .84
&7777A 1,04
1.19
Controlling outbreaks of
communicable diseases
Doing routine office work
and periodic reports
Running MCH and
family planning clinics
I
ZJ 1.14
(7777777771.32
1.4.5
Promoting latrines, pumps,
smokeless chulas, etc.
Conducting mass health
education meetings
ADMINISTRATIVE FUNCTIONS
I
1.94
77777^1.17
123
Holding staff meetings
for review and planning
Doing routine office work
and reports
'
'X.
'-,1 1.2S
I---------------- 1---------------- 1
0
12
Mean Frequency of Performance
Studying social structure
and functions in villages
Interest in Rural Service
1
_J None
Y//A Slight
Great or Moderate
] .83
(7777771.02
WKBBSBB1.12
1--------------1------------- 1
012
Mean Frequency of Performance
96
Doctors for the Villages
Fig. 6.16
Selected Opinions of Interns About Characteristics of Villagers
by Proportion of Urban Students in Three Groups of Medical Colleges *
Friendly
7
Medical Education
and Rural Internships
Cooperative
Industrious
Of special relevance to the practical question of what can be done to
get doctors into rural work is an evaluation of the impact of present
patterns of medical education and the rural internship. In the
questionnaires, we asked interns their opinions about their preparedness
for various types of professional work and estimates of their own
professional ability. We also asked them to make judgements about
the merit of specific activities in the internship; to record the time
actually spent on these activities; and to estimate how much they had
learned. Lastly, we asked how they thought the internship might be
improved.
Optimistic
Healthy
Trusting
Professional Preparedness
No Gossiping
Clean
I
" ' CZZLL3
fFSWMBrimi lliiril I —ZZZZJ
Dirty
U - Urban Colleges (more than 60% urban students)
M - Moderately Urban Colleges (45-55% urban students)
R- Rural College (12% urban students)
* Length of bar graph indicates the Mean Score of Opinions
Expectations obviously influence evaluation of preparedness, and
thus their responses can be judged only in relative terms. Rather than
attempting to set standard criteria against which judgements would be
made, we decided to have each intern score himself against his own
expectations of the demands that would be placed on him were he a
full-fledged professional. This was because we were specially interested
in whether their confidence in their own professional competence
would effect their willingness to serve in villages. From a list of ten
items, interns were asked to score on a four-point scale their responses
to the question, “Thus far in your training, how well do you feel that
you are prepared for each of the types of professional activities listed
below?"
98
Doctors for the Villages
The interns revealed a general feeling that they did not really feel
ready to assume independent professional responsibility (Fig. 7.1).
Tiie highest mean values were for work in government hospitals and
for urban private practice, but even these values were well below the
moderately prepared ranking. Ranked somewhat lower were rural
private practice and primary health centre work. Administrative
positions hi health and hospital services ranked last, after teaching and
service in the armed forces.
After the rural internship, the greatest improvement in selfconfidence expectedly occurred in reference to rural private practice
and primary health centre work. While this increased confidence is
encouraging, considering the purposes of the internship, the mean in
both instances still barely reached the midpoint of the scoring scale.
The relationship between general attitudes towards rural service
and the feeling of preparedness for primary health centre work is
strikingly shown in Figure 7.2. At the beginning of the internship,
those with greater interest in rural work felt better prepared for
primary health centre work than did those who had slight or no interest
in rural work. The group interested in rural work also registered the
maximum increase in feeling of preparedness at the end of the
internship. The mean score for those not interested recorded no
perceptible improvement and remained well below pporly prepared.
Those having slight interest showed a moderate gain during the
internship. Interns who were interested in primary health centre work
also felt better prepared for government hospital work and rural private
practice.
Cross-tabulations of preparedness against residential background
(Fig. 7.3) showed less marked differences than when related to interest
in rural service. Nevertheless, the residential background is of interest
because this variable may be useful as a basis for selecting medical
students. Interns with a rural background considered themselves
substantially better prepared for work in primary health centres than
did those with urban backgrounds. By contrast, the urban group
reported that they were better qualified to engage in urban private
practice and private specialty practice.
Expectations obviously
influenced this relationship.
Professional Ability
As a further exercise in self-evaluation, interns were asked to give
Medical Education and Rural Internships
99
an estimate of their ability to perform specific functions as compared
to their expectations of what a good doctor at their stage of develop
ment should be able to do. Sixteen functions were listed, and
evaluation was again on a four-point scale.
The highest score recorded was for their ability to establish good
relationships with patients and families, but this may merely reflect a
lack of appreciation of the spe
skills that are really required. Also
rated close to good were the skills of using simple clinical methods in
making a diagnosis, managing the treatment of patients, and suggesting
practical means for disease prevention (Fig. 7.4). Rated lowest was
their opinion about their ability in reference to a cluster of skills related
to public health and preventive medicine, such as being able to manage
and supervise a primary, health centre and to mobilize community
participation. The lowest score was for their ability to investigate
health problems and do research.
Interns who were interested in rural work scored themselves
higher for items relating to health centre work than did other groups
(Fig. 7.5). The greatest differences between those interested and those
not interested were in their estimates of their ability to manage and
supervise a primary health centre and to work with public health
auxiliary workers. The before and after questionnaires of all groups
showed an increase in confidence in this ability during internship.
Again, it is evident that the interns with greater interest in primary
health centre work seemed to have gained most from the experience.
Worthwhileness of Internship
To get some indication of the relationship between expectations
and the actual internship experience, we asked the interns at the begin
ning of their rural rotation to score nineteen activities according to
their anticipations of their relative worthwhileness. At the conclusion
of the internship, they were asked to rescore these activities in terms of
how worthwhile they had actually been. Generally, most activities were
seen as less worthwhile after the internship than had been anticipated
at the start. This was especially true of "control of communicable di
seases" and "inpatient care," both of which had been looked forward
to with considerable expectation. On the other hand, the high expect
ations for “outpatient care" were met (Fig. 7.6).
100
Doctors for the Villages
As shown in Figure 7.7, clinical care items (e.g., outpatient care,
maternal and child health, and family planning clinics) were considered
very worthwhile. Control of communicable diseases ranked second,
even though opinions about the worthwhileness of this activity declined
during tire internship. Community oriented and public health activities
were rated lowest (e.g., studying the community development organiza
tion, gathering routine data for administrative purposes, and field sur
veys). Didactic teaching was ranked very low (a realistic appraisal be
cause very little teaching took place in most of the internships). In
spite of all these deficiencies, it must be emphasized that seventeen of
the nineteen activities were rated moderately worthwhile or better.
In a continuing pattern, interns interest in rural service tended to
attach more value to public health and social medicine activities than
other groups (Fig. 7.8). Furthermore, those interested in rural service
showed greater acceptance of such activities as field surveys and time
spent in learning about rural life as being useful as a result of the
internship experience.
Knowledge Gained During Internship
The interns were asked to score on a five-point scale from
"nothing” to “very good” the amount of knowledge they had gained
in twelve areas (Fig. 7.9). The means for ten of the twelve items fell
between "fair” and "good, ” indicating a generally favourable appraisal.
It was encouraging that the interns reported that their greatest gain
in knowledge during their rural internship was an ability to learn from
practical experience, ability to establish good . relationships with
villagers, and an understanding of socio-economic factors in disease.
These are clearly among the main purposes of rural internship
programmes. Evidently, the least learning was in methods of research
and community surveys, the application of community health measures
and the organization of primary health centre activities — again,
activities that are also listed among the main purposes of the rural
internship, even though they are often largely ignored in day-to-day
work.
On the whole, those who were slightly interested in rural service
said that they had learned more during their internship than either of
Medical Education and Rural Internships
101
the other groups of interns (Fig. 7.10). Expectedly, the non-interested
group learned the least. The group with greatest interest reported
almost as much learning as the slightly interested group in knowledge
of rural life and ability to establish good village relationships. For the
items ability to learn from practical experience, getting along with
professional colleagues and auxiliaries, and understanding socio
economic factors in disease, the mean values for the slightly interested
groups were well above the scores of either of the other groups. This
suggests that learning was greater among those who, while not rejecting
the experience, were not as well informed initially as the greatly
interested group.
By cross-tabulating knowledge gained from the internship against
residential background of interns (Fig. 7.11), we found that those
with a rural background tended to report a somewhat greater gain in
knowledge during the internship than either of the other groups. This
applied even to such items as learning about rural life.
Finally, interns were asked to answer the open-ended question,
"How can the rural internship be improved?" Table 7.1 recorded the
frequency of twenty such responses according to sex and interest in
rural health centre work. The first three items in order of importance
were (a) improved living conditions; (b) improved health centre
equipment and resources; (c) better planning, guidance, organization,
and supervision of the internship. Male interns seemed more concerned
than females about living conditions. This was also true of the fourth
ranked issue of monetary benefits, with males showing much more
interest in pay than female interns. Interns who were greatly interested
in rural health centre service emphasized the need for improvement in
health centre equipment and resources more definitely than others.
Daily Log
Interns were asked to maintain a daily log of their activities so as
to provide descriptive information on how they were spending their
time. Pretesting included having them keep a daily diary, including
their subjective reactions to the village experience. While these made
fascinating reading, the results were impossible to quantify.
A very simple daily time record with precoded entries was finally
developed which seemed relatively easy td use and gave a simple
quantitative record. It did require, however, considerable effort from
COMMUNITY HEALTH CELi
326. V Main, I Block
Kmam.ngala
1
/ 3$
,,
■■■■
f
102
Doctors for the Villages
Medical Education and Rural Internships
the interns and from the social scientists who had to see that all forms
were completed. Data collected during the first year provided a clear
pattern of how the interns’ time during internship was being allocated.
It was, therefore, decided to discontinue the administration of daily
logs after the first year.
To show the range in responses, Table 7.2 presents the data on
the six medical colleges and the averages for all colleges. It is evident
that the biggest problem is that interns were not busy enough to be
stimulated, or perhaps conversely they were not stimulated enough to
keep busy. Almost seventeen hours per day were consumed in personal
activities, about five and a half hours a day were spent in professional
service, and about one and a half hours per day in direct educational
endeavors.
Differences between the internship programmes that stand out
are: the range from almost four hours to 0.1 hours in time spent in
curative work; a similar range in preventive work, health education and
family studies; all schools were making some effort to provide educa
tional experiences.
Supervisor's Check List
Another research instrument which was discontinued after the
first year was the Supervisor’s Check List. Although this represented
a theoretically important part of our data gathering, we reluctantly
stopped the effort because of resistance from the faculty members
responsible. They said that it required too much effort and that they
had too many interns to do an adequate job of scoring
their
performances.
Some results were gathered during 1963 on 143 interns from
five medical colleges which are shown in Figure 7.12.
103
Table 7.1
Measures for Improving Rural Internships
Suggested by Male and Female Interns
Female
(N-516)
Total
(N-1480)
50
46
37
39
46
44
33
26
34
9
33
20
More contacts with the rural areas
Greater independence and more responsibilities
More curative work
21
17
17
13
17
17
14
16
19
17
16
14
Better interpersonal relationships between interns
and health centre staff
Decrease duration
Increase duration
Less field work
13
15
11
16
9
6
9
More seminars, discussions and didactic teaching
7
More preventive work without clinical bias
5
Contact with PHC, its administration and function 7
More preventive work with clinical bias
3
More field work
4
I>ss seminars, discussions and didactic teaching
3
Less curative work
2
Miscellaneous
38
9
6
9
5
7
5
6
1
14
13
9
9
Male
(N-964)
Improved living conditions
Improved health centre equipment and resources
Better planning, guidance, organization and
supervision of internships
Monetary benefits
Improved quality and quantity of health centre
personnel
28
Percentages add up to more than 100% because of multiple suggestions.
7
6
6
6
4
4
2
34
Table 7.2
Average Number of Hours Spent per Day on Different Activities by Rural Interns at Six Indian Medical Coileges
'———“
6
An Colleges
"
"
“
4
6
0.5
0.6
1.1
0.1
0.0
0.4
0.2
2.4
3.1
0.3
0.1
0.1
0.1
0.2
0.1
1.0
0.1
0.0
0.5
1.1
0.4
0.6
0.0
2.4
1.6
0.1
0.1
0.1
0.5
0.0
0.0
2.0
1.1
1.4
0.4
0.1
0.2
0.1
0.0
0.7
3.8
2.0
0.2
0.1
0.1
0.0
0.2
1.2___
1.9
0.9
0.4
0.2
0.2
0.2
0.1
1.7
5.3
5.0
5.1
4.4
4.0
7.6
5.6
0.4
0.2
0.3
0.2
0.9
0.1
0.8
0.7
0.4
1.2
0.4
0.0
0.5
0.5
0.0
0.5
0.7
0.1
0.6
0.5
0.2
0.9
1.2
1.9
1.6
1.0
1.3
1.3
7.1
6.0
8.6
3.8
2.2
1.5
0.6
9.2
3.8
2.2
1.1
1.6
10.0
3.6
1.9
1.5
1.7
8.1
2.8
1.8
1.5
0.9
8.5
3.7
2.1
(k9
8.2
2.4
93
14
1.1
15.4
2.4
16.7
0.3
17.9
0.1
18.7
0.3
15.1
0.0
unaccounted i nne_____________________
17.8
0.0
16.7
0.4
175
111
99
96
273
92
846
INumoer OI Xveturna___ ________________
28
36
13
174
'
PROFESSIONAL SERVICES
Curative Work at Teaching Centre
Preventive Work on Comprehensive Care
Health Education Work
Studying Families
Individual Research
Personal Contacts
Gathering Data
Other Professional Work
EDUCATIONAL ACTIVITIES
Seminars
Reading Medical Literature
Discussions with Teaching Staff
Sleeping
Indoor and Outdoor Recreation
Eating
Personal Grooming
Reading Novels, etc.
Number of Interns_____________________ ___________ 40
R
I
w
26
31
1.0
Fig. 7.2
Interns’ Estimates of Their Preparedness for Various Professional Activities
Compared With Interest in Rural Service
(Before and After Internship)
After (Rural Internship)
Interns’ Estimates of Their Preparedness for Various Professional Activities
Compared With Residential Background
| After (Rural Internship)
Before
U - Urban
M « Mixed
R “ Rural
Medical Education and Rural Internships
Fig. 7.3
Doctors for the Villages
Before
N = None
S = Slight
G = Great or Moderate
Doctors for the Villages
IOS
109
Medical Education and Rural Internships
Fig. 7.4
Interns’ Estimates of Skill in Performing Selected Activities
Fig. 7.5
Interns’ Estimates of Ability to Perform Selected Activities
(After Internship)
O
c
$
Mean Estimate of Ability
II!HS J° aieuipsa uea^
Q>
110
Doctors for the Villages
111
Medical Education and Rural Internships
Fig. 7.7
Fig. 7.6
Interns’ Opinions About Worthwhileness of Selected Activities
Interns’ Opinions About Worthwhileness of Selected Activities
(Before and After Internship)
(After Internship)
Out-Patient Care
.. .
L
Control of
Communicable Diseases
l . .
L...
MCH and
Family Planning Clinics
L_,
School Health
.
1 1.71
Out-Patient Care
I
------- 1
1.66
Communicable Disease Control
I
_____ ZU
MCH, Family Planning Clinics
I
"ZZJ
School Health
I
Reading Medical Literature
Individual Discussion
With Teaching Staff
I
• ZZ1
I
..ZZJ
Seminars with Teaching Staff
I
------------ Z2
Environmental Sanitation
I
’ ~ ~'1
In-Patient Care
L.
... '.J
Learn About Rural Life
I
"1
Specialty Clinics
I
........... ~i
Family Care
F ~ ' ~~"Z3
Community Health
I
Preventive Services
I'
■
Vital Statistics
I
-------- 1
Field Survey
1
-~il
Didactic Teaching
I
___ J
Gathering Routine Data
r
1
Study Development Block
r~. .1
I 1.73
'7'1 1.58
I 1.57
3 2.55
I.
_______ I 2.50
2.46
In-Patient Care
I 2.63
I.
2.33
Field Survey
I
1 .94
1.04
Didactic Teaching
I
I,,-- ~-z7z
Gathering Routine Data
I-------- J .69
~~l 1.06
3 j 00
.72
Study Development Block
I____ __ J .78
.72
I--------------------1------------------ t------------------ 1
0
12
3
|
| Before
After (Rural Internship)
Mean Estimate of Worthwhileness
—
~~1
0
'1
12
3
Mean Estimate of Worthwhileness
112
Doctors for the Villages
Medical Education and Rural Internships
Fig. 7.8
Interns’ Opinions About Worthwhileness of Selected Activities
Compared With Interest in Rural Service
(After Internship)
Fig. 7.9
Interns’ Opinions of What They Learned During Internship
(After Internship)
MCH and Family Planning Clinics
School Health
1
... - ■
1
Environmental Sanitation
1_________ 1
z/zd
Learn About Rural Life
1________ 1
K/ZZZ///ZV///d
Community Health Services
and Health Education
Preventive Services for
Individual Patients
1________ 1
1________ 1
L'/Z////Z/ZZZd
1_______ 1
Vital Statistics
Gathering Routine Data
1____ 1
1____ 1
Study of Block Organization
Interest in Rural Service
1_____ 1 None
V///A Slight
KMH Great or Moderate
o------------ 1----------- i—
Mean Estimate of Worthwhileness
113
Doctors for the Villages
114
115
Medical Education and Rural Internships
Fig. 7.10
Fig. 7.11
Interns* Opinions of What They Learned During Internship
Interns’ Opinions of What They Learned During Internship
Compared With Interest in Rural Service
Compared With Residential Background
r
•—
Establishing good relationships
with villagers
i
Learning from practical
experience
EZ_•
.
l
Understanding socio-economic
factors in disease
Establishing good relationships
with villagers
I
z)
XZZZ7ZZZZ7Z77Z77ZZZZ/ZA
Learning about rural life
i
r—
Health education
Getting along with professional
colleagues and auxiliaries
■M
Clinical practice under
rural conditions
I------------------------- --2J
777777777777777777777
Understanding socio-economic
factors in disease
....
I
Learning about rural life
Applying principles of
prevention in clinical practice
---------- 1
a
Y/7/7/777///7777////7&
. .J
I
Organizing primary health
centres
I
Organizing primary
health centres
.2=J
1
.VZZZZZZZZZZZZZZZZ&
H
| None
V/7/A Slight
r;sa Great or Moderate
Interest in Rural Service
Applying mass community
health measures
4
Mean Knowledge Gained
V/77777777777777
I
—I Urban
V//7A Mixed
K2-533 Rural
Residential Background
J
...
777777/77/77777
i---------------- 1---------------- 1---------------- 1----------------1
0
12
3
4
Mean Knowledge Gained
Doctors for the Villages
116
8
Fig. 7.12
Supervisors’ Rating of Rural Interns at End of Internship
and Improvement During Internship
(1963 Only)
General diagnostic ability
□===□
Ability to apply
clinical treatment
iMKKJWimKEMKi
Professional Skills
Professional relationships and
administrative ability
C
I
J
i
i
|kwk^\x\x\x\x\xxv|
Understanding and ability to
apply principles of prevention
in clinical practice
laagMCiKKKgKMssi
E==]
J
i
Ability to apply community
health measures
I
Understanding of causation,
natural history and
epidemiology of disease
1
Ability to use epidemiological
information to aid clinical
diagnosis
I
Ability to see
community as a whole
~
|
|\\\\\\\|
Through the years, innumerable political speeches have exhorted
doctors to go to the villages. Socially conscious medical educators
have criticized themselves because they have not been able to imbue
their graduates with either the orientation or the motivation to serve
rural people.
Early in this research it became evident that the whole rural health
care system is inadequate and at fault, not medical education alone.
The blame for the lack of health care in villages cannot be placed on
doctors alone. The deficiencies of doctors, both numerically and in
their preparation, are only a part of a more general problem. Doctors
cannot be effective in rural health centres until these peripheral units
are made decent places for doctors to work. With the progressive
improvement of physical facilities in health centres in some states of
India, it is increasingly evident that there are even more serious
organizational problems. From a continuing series of research projects
at Narangwal, we have learned a great deal about what is needed in the
reorganization of the rural health system.
Basic Elements of the Health Centre Approach
IXXXVXWKWK*^
I--------------- 1--------------- 1--------------- »0
12
3
|
a New Rural Health System
-------- 1
Ability to create rapport
with patients and families
Understanding socio-economic
factors in management of
disease
The Need for
Status at end of internship
Improvement during internship
Mean Rating
The problems of the rural health system are so fundamental that
various partial and piecemeal efforts to reorganize services have
obviously not been radical enough. The Bhore Committee and sub
sequent planning groups conceptualized a regionalized comprehensive
care system that made good theoretical sense. Progressively there has
been considerable advance in providing the structure of the system, but
The Need for a New Rural Health System
ns
119
Doctors for the Villages
there are major gaps and it has never developed smoothly functioning
interrelationships.
In the first volume to come out of our Narangwal studies (Takulia
et al, 1967), we described the twelve basic elements of the health centre
approach; these are summarized in Chapter 1. An all-or-none principle
was defined. We postulated that it is necessary to reorganize all these
elements in order to get the system to function effectively. In the past
there was too much tinkering in that only two or three elements would
be changed at a time. One of the most deleterious aspects of the
present system is the continuing tendency to carry to the villages the
western health care pattern, exemplified by private practice and
hospital outpatient services, with the physician functioning only as a
solo practitioner.
Traditionally, health services tended merely to respond to
patients’ initiatives as they came seeking health care. As the orientation
now shifts to include the preventive part of comprehensive care, it
becomes increasingly essential chat the health services take the initiative.
This, in turn, requires a clear definition of professionally determined
need in the community in addition to just responding to individual
patient demand. A balance must be maintained with participation of
the whole community in planning which leads to local determination
of priorities.
Mass Needs of Villages Cannot be Met by Doctors Alone
A fundamental reality is that doctors can never meet the mass
needs of villages by themselves. Doctors will not go to remote villages
in sufficient numbers, and it is increasingly evident that the government
would not be able to pay all of them if they did go (Alexander 1966).
Evidence gathered in our research demonstrates clearly that the
expectations of both the medical profession and society generally are
such that the physician will probably still be expected to fill the role
of leader of the health team. Expectations must change, however, to1/
recognize that he should not be required personally to try to provide
all primary’ medical care. Furthermore, the analyses show that this
trend is probably appropriate in ensuring tire best use of physicians’
ume. A whole new orientation and role for the doctor will have to be
worked out as the health system is rationalized and this will require
major changes in present orientation and preparation.
s
This study showed that young doctors reflect general urban
attitudes in ranking highest those clinical specialties that have particular
dramatic appeal (Fig. 5.1). The order in which clinical specialties were
ranked suggests rather clearly that the drama of prompt cure is a
dominant factor in social prestige, recognition, and remuneration. The
ranking, progressively moving downward from surgery to public health,
suggests that those preventive and community activities which lead to
deferred and less dramatic results have minimal prestige, even though
they may in fact produce greater improvement in general health.
A similar orientation is reflected in the interns’ choices of types
of professional activity—with the rank ordering ranging from specialty
private practice at the top to primary health centre work at the bottom
(Fig. 5.2). That this is not related solely to financial remuneration is
indicated by the importance accorded to intellectual satisfaction, the
factor ranked highest in career choice (Fig. 5.7).
The fact that rural service has little appeal as a career is neither a
surprise nor an insuperable obstacle. Doctors may be willing to go to
the villages, but conditions will have to be modified first. There seems
little reason to expect many doctors to develop missionary motivation.
But this study has clearly shown that most doctors are willing to serve
in rural health centres if basic personal and professional considerations
, are met. Almost equally important, they do not want to be stuck in a
\ rural setting for life (Fig. 6.1).
Three observations support the interns’ intuitive recognition that
the solution does not lie in a massive flow of doctors to the villages.
The fundamental problem is economic. Few villages can afford to pay
doctors the remuneration they expect in solo practice of primary
medical care. Doctors are too expensive, and modem medical care
costs too much. Nor does it make sense to prepare a highly skilled
professional to use sophisticated techniques and equipment and then
put him in situations where he does not have access to such expensive
facilities.
It follows, then, that a health manpower policy that concentrates
mainly on producing doctors is inappropriate.
An unbalanced
educational system concentrating mainly on training doctors makes
neither political nor economic sense. The cost of medical education
by itself requires that their numbers should be smaller than the
supporting categories of paramedical professionals and auxiliaries
Many developing countries have, however, rushed into unbalanced
120
Doctors for the Villages
production of doctors, partly because doctor-population ratios have
become prestigious, international indicators of a developed health
system. Recent pressures to open more medical colleges also show
that many families want to expand medical education to provide
career opportunities for their children. The resulting distortions
produce a manpower profile shaped like an hourglass rather than a
pyramid, with only a few health workers supporting the doctors and a
large number of indigenous health practitioners working independently
in the villages. Rational manpower planning requires a truly pyramidal \
balance between doctors and auxiliaries to get the most cost-effective |
manpower mix.
Finally, we observe that efforts to provide all medical care by
doctors does not necessarily result in the best health care. Auxiliaries,
trained specifically to do particular routine jobs, seem better able to
produce a consistent quality of work than tire more broadly prepared
doctors. This is especially true in situations where auxiliaries are closer
to the people and can, because of this, apply prompt care which can
offset further progression and complications. The auxiliary learns a
routine and tends to be satisfied to carry it out. A doctor forced into
a position where he is performing only rather simple routine tasks >
quickly becomes bored, dissatisfied, and ineffectual.
The fact is that primary medical care tends to be monotonous
because common illnesses are readily cared for by routine procedures.
Doctors in solo practice tend to fall quickly into what Osler called
“penny in tire slot” patterns of practice, with a statement of a chief
complaint eliciting a reflexive prescriptive response. One director of
health services told one of us that a PHC doctor had been commended
officially because he was seeing 700 patients in a morning. Detailed
work studies of more typical health centres indicate time allocation of
an average of one to two minutes per patient. Even with this ridicu
lously high work output, the doctor can only serve fewer than 5,000
people living within a few miles of his health centre, rather than a
whole community development block of more than 80,000 people.
A heavy load of curative work has emerged, then, as a primary
obstacle to tire effective provision of comprehensive care. As long as
doctors are overloaded as they try unsuccessfully to meet the mass
demand for care of simple illnesses, there is little chance that they
will effectively organize a health team to provide an appropriate
balance of preventive work. Because of archaic traditions that make
The Deed jor u 2VcU/ j
clinical care the particular preserve of doctors, preventive work has
been delegated to auxiliaries, with the subtle implication that
preventive services are relatively unimportant and simple. There is
also an implication that if preventive services are improperly done
there will be less potential for doing harm than with curative work.
In our continuing rural health research (Taylor and Takulia
1971; Taylor 1970), we have tried to get away from professional
stereotypes and develop a more rational definition of the doctor’s
role. We have attempted to reallocate functions in the health team on
the basis of careful evaluation of the skills and competence required
to perform specific activities. The principle is that all functions that
can be easily routinized should be assigned to appropriately trained
auxiliaries or paramedical workers.
Only tasks requiring broad
understanding, the judgement to make complicated decisions, or
complex skills should be referred to doctors. We found that ninety
percent of primary medical care was, in fact, easily routinized and
simply treated, while the other ten percent can consume as much time
and money as can be made available. Auxiliaries can be trained to
diagnose common conditions on the basis of symptoms and simple
findings. Then, clear instructions for prevention and treatment can
be built into standing orders (Uberoi et al 1974).
Furthermore, simple routines for referral to a physician can be
based on well defined findings or the patient’s failure to respond to
standard treatment in a specified time. The screening function is a
relatively straightforward skill which can be taught. In fact, too much
medical knowledge is likely to interfere with efficiency in this kind of
routine task because knowledge of all the alternatives is distracting.
The more sophisticated a community becomes, the more they can
learn to take care of routine problems themselves. Oftentimes health
centres in developing countries are crowded partly because people are
still sorting out the relative value of various systems of medicine.
Because they are still not sure what scientific modem medicine will
cure most readily, they bring all their minor complaints for diagnosis.
For referral procedures to function efficiently, an information
system should be set up to record unfortunate sequelae. If they
become recognizably frequent, they can be identified as having special
priority, and special referral routines can then be established. Since
such special routines must be sharply limited to the highest priority
122
Doctors for the Villages
problems, the guiding principle in keeping the standing orders simple
must be the general public health dictum that the objective is adequate
care for all rather than unlimited care for a select few.
Preventive routines also may be either routine or complex. Some
mass preventive measures can be almost mechanistic—for example,
spraying for malaria, routine weighing in nutrition surveys, doing
immunizations, or conducting environmental control procedures. The
types of preventive services that require changes in personal living
habits and those that involve community diagnosis and measures to
introduce social change, however, have as much variety, uncertainty,
and intellectual challenge as the ten percent of clinical cases which
need referral for specialized care. During a home visit, for instance,
considerable social and scientific sophistication may be needed to work
out the dynamics of changing personal living habits. How can one
routinize the greatest mass need of all in India, which is to standardize
the motivational approaches that will convince parents to practice
family planning? These skills require sociological, psychological, and
community training for all members of the health team.
To have auxiliaries distributed in subcentres throughout the
health centre area, is also tire only way that medical services can be
made geographically accessible to all tire villages of a community
development block. Women and children do not have tire mobility of
men who can get on a bicycle and travel to a health centre several
miles away. Coverage should be increased by ensuring that a subcentre
is within a mile or two of every village family, and that the auxiliary
staff there can provide comprehensive primary care.
The realities of the rural health situation require an inversion of
present roles in the health team. Instead of doctors providing curative
care and auxiliaries doing the preventive work, the delegation of
responsibility for both curative and preventive services should be
based only on whether safe routines can be established. Doctors can
function effectively as leaders of health centre teams only if they are
relieved of responsibility for the ninety percent of curative care that
deals with common and uncomplicated illnesses in a system that
provides screening for the more serious conditions. There must be a
concurrent reorganization of medical education and the training of
other members of the health team. Even more fundamentally, the
The Need for a New Rural Health System
123
whole system of values must be changed to revise medical ethics to
accept these changed roles.
Role Definitions in the Health Team
Two divergent points of view need to be placed in perspective in
the current crisis of medical care in most countries of the world. They
are the contrasting scientifically based professional view of doctors and
the public’s view of what happens to them when they are sick.
Doctors increasingly consider the traditional public image of the
family doctor to be mostly a sentimental nostalgia for a pattern of
service which is increasingly difficult to achieve in the modem world,
and essentially impossible in poor countries. It is well to remember
that the memory of the family physician is cherished by the limited
public in most of the world who really had access to general
practitioners. The present trend among affluent groups is to reestablish
family medicine by raising it to the status of a specialty. The content
of medical knowledge and the range of medical skills is too great to be
handled by any one person. Specialization is growing because doctors
feel that it is necessary for them to focus their learning and skills fairly
narrowly in order to have the personal satisfaction that is derived from
competent performance. Doctors generally feel obliged to handle
common problems with a thoroughness that will take into account rare
possibilities in differential diagnosis and complications, and only the
affluent can pay for this service.
In today’s trend toward specialization, then, the growing problem
is for patients to find primary care physicians with sufficient generalist
understanding to keep the whole range of their health needs in
perspective and to help the patient find his way among the maze of
specialists. A good specialist can usually diagnose elusive and compli
cated medical problems in a shorter time and with more precision than
a general practitioner-provided, of course, that the patient gets to the
right specialist. In tire meantime, however, tire patient usually suffers
the hazards of progressing disease and the cost and personal danger of
inappropriate diagnostic and therapeutic measures.
The public, nevertheless, continues to be concerned with matters
which have been ignored in the scientific era of medical progress. They
124
Doctors for the Villages
want a doctor-patient relationship that includes hand-holding and time
spent in explanation. These qualities provide a basis for confidence;
patients feel tire need for someone who cares, someone to whom they
can turn over tire worries associated with ill health.
For most of the people of the world, there seems to be no way in
which the combined functions of applying the best of medical wisdom
and technical skills on the one hand, and human caring and emotional
support on the other, can be built into a one-to-one continuing human
relationship with a single family doctor. Even the most affluent are
having trouble gaining access to such care. To apply the best expertise
within reasonable constraints of efficiency and economy, we are having
to turn to organization of multiple skills within a system. People are
not used to personalizing a system sufficiently to develop real confi
dence in and affection for it. We must, however, learn to approximate
the ideal in a way that provides more equalization of access to services.
People want to know that their needs have, at least, been taken into
account.
An effective health system, then, requires two components. First,
the primary care contact should be the point at which the continuing
human support relationship needs most to be developed. This is where
kindness and caring must be evident in a personalized relationship with
an individual who is readily accessible. With such a person to do the
interpreting, it will then be easier to encourage the impression, and
hopefully the reality, of caring in the whole system. The second
characteristic of an ideal system requires the development of mech
anisms so that the technical needs of patients will be cared for by the
person who can best and most efficiently and economically apply
appropriate specialized skills and understanding in diagnosis, therapy,
and prevention. Such a system requires a good screening procedure
and easily accessible referral.
To allocate responsibilities rationally, it would seem best to enlist
for the primary care contact persons who have come from a social and
educational level relatively close to the community they serve. Unfort
unately, this seems to imply that more affluent, educated groups will
have access to more highly trained family doctors, while poor and
uneducated groups will have to be satisfied with someone closer to
their own group who will probably be an auxiliary. This arrangement
seems realistic, though, in improving care patterns because it is well
known that professionals who are socially distant from the communi
ties they serve have trouble in bridging the wide interpersonal gap.
The Need for a Neu> Rural Health System
125
Such professionals can, however, bring prestige and support to an
auxiliary. On the other hand, it is also important that the primary
care person should immediately command respect in the community,
and this requires a readily recognized level of special preparation and a
widely supported process of building up the distinctive image of the
health care auxiliary.
When a highly trained professional has to perform routine and
bo.mg tasks in mass primary care, his only recompense for the lack of
intellectual challenge will be some other direct reward. For instance,
a doctor will attend faithfully to the care of normal colds, Monday
morning headaches, and smoker’s cough only if he is paid well, if his
patient is politically powerful or socially prestigious, if he happens to
be unusually chantable, or if he just cannot find any other way to
make a living. A doctor with an affluent private practice of simple
illnesses may rationalize his contribution by stressing the need for
considering abstruse possibilities in making a differential diagnosis in
order to add a few percentage points of better care for important
patients, or he might get his gratification from the contribution he
occasionally makes by encouraging personal preventive measures such
as stopping smoking.
By contrast, if the lack of prestige can be overcome, with
changed role expectations, motivation and training, many doctors
could find the role of being a community physician challenging and
attractive. They can work through a team of auxiliaries to reach large
populations and can learn to cope with complex community problems.
In an increasing number of countries, even those which have been
considered affluent, economic constraints are forcing the new approach
to mass comprehensive care based on paramedical or auxiliary workers.
To make the system run efficiently, attention must also be paid to
the logistics of transport and communication. Records must move
with the patient, both centripetally and centrifugally, as he is referred
to appropriate specialists and then returns home. Both at the periphery
and centrally in the regionalized system, each stage needs the benefit of
a summary of what others have learned and prescribed. But at each
stage, responsibility should move with the referral.
Perhaps most important for maintaining the service tone in such a
system is routine but not regular (in the sense of being expected) visits
by trained supervisors to support auxiliary workers. This supervision
must be educational rather than punitive. If an effective career ladder
126
Doctors for the Villages
The Need for a New Rural Health System
within the system has been developed, one feature in the selection of
those who will move up should be the opinion of field supervisors.
This selection, then, would go beyond academic performance. A
specific characteristic found in the good professional is the ability to
balance alternatives in complex judgements. To maintain a quality of
caring throughout the system, the selection process should also ensure
consideration of community reactions and an opportunity to reflect
their feelings about whether the individual being considered for
employment or advancement is one to whom they would like to go
for health care.
It is evident that doctors need special preparation to manage a
health team. While the general idea of integration has been widely
accepted for some time, all that has been done practically has been
to throw traditionally trained doctors into a village setting with the
exhortation that they be team leaders. Comprehensive community
care includes some of tire more complex arts in the practice of
medicine. Rather than expecting the recent medical graduate to solve
such problems without guidance, the management problems require
concentrated research attention. The findings that come out of
research must then become a part of medical training.
It is the professors who should go to the field to develop the new
health system, rather than hiding in the protective security of teaching
hospitals.
Clinical professors are especially needed because they,
presumably, can separate out the core of what is absolutely essential
from ritualistic fringe activities in medical care. They should also be
better able to apply cost-benefit judgements in developing routines of
simple care to meet the mass needs. A better balance should be
achieved between field research on practical problems and the general
tendency to do increasingly sophisticated and expensive studies on
rare diseases.
Comprehensive care packages of service must be designed to
integrate activities. When a mass campaign is developed for malaria,
it remains efficient only as long as a particular pattern of coverage
with DDT spraying is maintained for a large number of people. When
malaria programmes reach the maintainance phase, they must be inte
grated with basic health services, even though this is difficult. It has
proved inefficient to send health workers to villages to do only one
task and then have several different types of workers trying to make
home visits. The new comprehensive care package can be designed to
127
get maximum trade-offs between those activities that will be syner
gistic. Our other projects at Narangwal have shown that services can
be designed in field research to produce simple service packages for
women’s services, child care and family planning which are appropriate
for replication and mass implementation. There is need for field
research on the whole comprehensive care package.
Political considerations are increasingly requiring a more uniform
distribution of health manpower over the total population. This is a
direct move away from the focussing which results from the attraction
of urban centres for doctors. A phased approach seems necessary
during an interim period. One compromise has been to draw intensive
coverage circles for limited populations immediately around health
centres and subcentres. The full package of comprehensive care is
provided only in the intensive area, while people can come on their
own initiative from the wider areas.
Simple but extremely important geographical limitations control
the coverage that can be expected from one subcentre. A common
mistake is to try to get health auxiliaries to cover too large a
population. In our functional analysis of health centres (Reinke et al,
1974), we found that in Mysore, where auxiliary nurse-midwives were
expected to cover 10,000 population, they spent forty-five percent of
their time just walking from home to home. In the Punjab, with the
same general coverage of a subcentre population, ANM’s were only
required to do home visiting in an intensive area of 3,000 population;
here they only spent twenty-three percent of their time in travel.
Local transport arrangements and distance between population units
will influence the balance between work and travel. But in general it
seems reasonable to have more multipurpose auxiliaries travelling
shorter distances, even if this means spending the same amount of
money to hire workers who are less qualified in their training. To
develop maximum coverage within constraints of cost, such minimally
trained auxiliary personnel may have to focus their activities on the
most limited and simple components of the service package. Having
several single-purpose workers obviously multiplies travel time. Since
people tend to be more expensive than improved transportation,
greater use should also be made of simple technology, such as bicyles.
Perhaps the greatest reduction of cost in the functional redistribu
tion of roles in the health team will come from moving responsibilities
back into the community. Many of the acute and common illnesses
128
Doctors for the Villages
which overload the present health centres can readily be cared for in
the family. Self-treatment or maternal treatment of minor complaints
can be increased through health education. For instance, most of the
severe morbidity from the massive prevalence of diarrheas among
children could be readily prevented by early oral fluid-replacement
therapy. If packages of the appropriate salts to be mixed with water,
with clear instructions for their use were available in all village homes,
the need for much time-consuming medical care for rehydration would
be greatly reduced.
The Highest Priority - Family Planning and. MCH
The greatest health problem in India is rapid population growth.
Tire unfavourable effects on the physical, emotional and social
well-being of individuals, families and communities have been well
documented (WHO 1970). As with other mass health problems of
high priority, early stages of program development may be amenable
to a mass campaign approach. In India, such approaches have thus far
dominated the family planning effort, with sterilization camps having
received the greatest publicity.
Indian policy has, however, moved toward recognition of the
need for the long, slow effort of building continuing local services
that integrate health and family planning. Family planning and health
have a two-way interaction. Not only is family planning a principal
means of improving maternal and child health, but maternal and child
health also greatly strengthens family planning.
Up to an as yet undefined threshold of socio-economic develop
ment, health motivations are probably more important in gaining
consistent practice of family planning than other factors such as
education, economics, and the status of women. Among the health
motivations for family planning, the most clearly identified are those
that relate to maternal health. The success of post-partum programs
is a clear indication of the readiness with which women accept family
planning when it is provided in the context of maternal care.
A presumably important but little understood relationship is the
effect of child health and survival on family planning motivation. The
common sense notion, which has yet to be scientifically demonstrated,
is that it is unrealistic to expect parents to stop having children until
they have some assurance that those they already have are going to
The Need for a New Rural Health System
129
survive (Omran 1971; Taylor 1965; Taylor and Hall 1967; Taylor
et al 1974). This child survival hypothesis presumably is subconscious
and conditioned by expectations that are developed during an
individual’s own early experiences. If one’s siblings and friends died
early, then there is a built-in subconscious feeling that extra children
are needed to end up with the desired number. When children’s
survival is assured, it would presumably take at least one generation
for these expectations to shift. The integration of family planning
with child care could set up conditions for reducing this lag period
(Taylor and Takulia 1971).
In addition to mortality expectations, there is perhaps an even
stronger effect of morbidity (Taylor 1970). Illnesses of children seem
to influence family planning motivation, and our research at Narangwal
suggests that the care of certain illnesses, such as marasmus, have more
impact than general medical care in demonstrating the availability and
effectiveness of child care.
At Narangwal since 1966, a major research project has been
defining the relative impact on family planning utilization of various
modules of health service input (Taylor and Takulia 1971). We have
shown that it is possible to develop an integrated village-based service
using family health workers to provide ninety percent of medical care,
as well as nutrition, immunization, pre- and post-natal care, and family
planning. For deliveries, we have learned that it is best to support the
dai (indigenous midwife) rather than trying to replace her. There are
several key elements in making such a service module work. First,
there should be weekly supportive supervisory visits by a family health
supervisor and separately by a doctor to see referred patients and to
help with community diagnosis. There should also be one-day training
sessions every other week when all auxiliaries are brought into the
centre for intensive sharing of experiences and working out new
solutions. Furthermore, there needs to be adequate logistic support.
The family health worker should have access to medicine and
procedures that really work, rather than being left in a poor competi
tive position with indigenous practitioners who preferentially search
out the strongest western medicines. Perhaps most important, there
must be standing orders and operating manuals that are clear and
practical.
Built into the health care routines are a series of “entry points”
for family planning. These include those points in the reproductive
cycle when parents are most ready to talk about family planning.
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Doctors for the Villages
Willingness of Doctors to Work in New Health System
Perhaps the greatest contribution of this study is the optimistic
finding that these doctors reported that they were ready to go to the
villages if better professional and personal conditions of service were
provided (Fig. 6.1). The motivations of these young medical
graduates seem sincere, realistic and relatively humanitarian. They rate
professional blocks to rural service of greater importance than personal
considerations (Fig. 6.7). It is worth noting that the problems that
bother them most are ones which can be corrected.
At the top of the list in all geographical areas was concern
about the lack of drugs and supplies. The only reason given for the
remarkably frugal practice of providing a bare minimum of drugs and
supplies to health centres is the fear that they will be sold for personal
profit. This argument is not valid economically. A total investment of
lakhs of rupees (100,000 rupees) in the health centre and its staff is
essentially cancelled out just in order to prevent the possible waste of
a few thousand rupees which might be lost in black market drugs.
Surely administrators can find better ways of controlling drug
inventories than by emasculating the whole service. One alternative
would be to encourage panchayats (village councils) to put up money
raised from the village people to pay for the drugs in health centres
and subcentres. Villagers are usually more ready to pay for drugs than
for any other item. Then, if this is clearly identified as their own
money, highly effective local controls will develop automatically,
since villagers do not take kindly to anyone wasting their money as
distinguished from what they view as being the Government’s money.
Experimentation is needed to develop health insurance mechanisms to
distribute costs of local services to the consumers.
The next three professional obstacles to recruiting doctors to
village service relate to the difficulties rural doctors experience in
maintaining their professional competence. Particularly important is
lack of opportunity for professional advancement. This was also
frequently expressed in the concern that once they got out in a village,
everyone and especially their superiors and medical teachers would
tend to forget about them. Then, ranked almost as highly are concerns
about the lack of opportunities for postgraduate education, poor access
to libraries and reference materials, and scarce opportunities for
consultation. These are reasonable concerns with readily available
and effective solutions.
The Need for a New Rural Health System
131
Among the alternative solutions, the most desirable would be to
develop a regionalized relationship in which medical colleges reach out
to the health centres. If medical college faculties were to develop an
interest in or perhaps to take responsibility for the primary health
centres in districts around them, they could keep in touch in a
number of practical ways. These might include periodic seminars and
refresher courses at the medical colleges. Even if a PHC doctor were
visited only twice a year, it would do a great deal for his morale.
Medical college libraries could circulate information and literature
through many different technical media. More elaborate possibilities
include innovations such as a radio network.
Another major but relatively simple administrative device would
be to ensure rotation out of a village assignment to compensate for the
intern’s fear that he will “get stuck in the village for life.” Many young
doctors say they would put in a period of service in villages at an early
stage of their careers, before they have school-age children. Village
service should be made a prerequisite to any kind of professional
advancement, whether it be post-graduate training, advancement in
government service, or a foreign fellowship. Two years of service by
all medical college graduates would staff every health centre in India.
A final point needs to be made about the recognition and prestige
accorded to village service. The medical social structure clearly puts
health centre service and preventive work at a low level, of virtual
untouchability. The real excitement and challenge of community
medicine can and should be built into the career expectations of
doctors and of society at large. Symbols may be important, such as an
annual award to the best PHC doctor in a state or a district. The fact
that low salary ranked eighth among the obstacles to rural service
shows that doctors’ motivations are not purely materialistic. Adequate
rural allowances would, of course, be an important way to show that
the special contributions of rural doctors were being recognized.
Another simple device would be to make sure that at least one village
doctor is asked to present a paper at each medical conference.
Similarly, they could be encouraged to publish in medical journals.
Occasional articles in newspapers and magazines about a particularly
effective health centre team would influence favourable
public
recognition.
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Doctors for the Villages
reallocating roles. In particular, routine medical care must be turned
over to auxiliaries to permit professionals to concentrate on the more
complex problems, especially those involving community diagnosis and
therapy. Young doctors are reasonable in recognizing their responsi
bility to provide comprehensive village care if it can be done as a rural
rotation early in their medical careers. But such rules should apply
uniformly to everyone. Presumably this will lead to more effective
selection of those few who will choose rural and family medicine as a
specialty and will move to positions of leadership in improving rural
services.
9
A New Pattern of
Rural Medical Education
The health system can be changed only if the orientation of the people
who make up the system is changed.
Medical education in India is still too much a replica of British
medical education of fifty years ago. Most systems of medical
education around the world share the same problems, although there
have been significant efforts at reform in the past twenty years. In
India, modifications have consisted principally of adding new course
material, often without sufficient cutting of lower priority material
to make room in the curriculum. Much of the specialized information
now included is useful only to clinical specialists in particular fields.
It is almost inevitable that when specialists do most of the teaching,
they will emphasize what they know best.
The crowded curriculum has jeopardized preliminary efforts in the
last twenty years to introduce a community orientation. Curriculum
congestion also causes a rigidification of both content and methods of
teaching. Students have no time for anything but rote, didactic
learning to pass the examination hurdles. The situation has been
sharply aggravated by a massive expansion in both numbers of colleges
and sizes of classes. Overwhelming shortages of qualified teachers and
adequate facilities created concerns about quality control which led to
an unhappy fixation of inflexible patterns in the mass production of
doctors.
In the medical profession generally, a serious decline in the spirit
of scientific enquiry, a lack of innovative sharing of wisdom and
experience to new generations of doctors, and especially a diminishing
evidence of a sincere and dedicated concern for service have been noted
in many speeches by medical leaders over recent years. That these
A New Pattern of Rural Medical Education
136
137
Doctors for the Villages
concerns are shared by the public is indicated by numerous letters to
newspaper editors. There has been a growing awareness that the
present trends must be reversed. The real leaders of medical education
and health services have been making slow but steady progress in
finding solutions, rather than just joining in the recriminations.
India has been caught in an acute manifestation of a manpower
planning crisis that we have referred to elsewhere as “The QualitativeQuantitative Dilemma.” (Taylor et al 1968) Under the British Raj,
the emphasis was to limit the coverage of health services to a select few
but to maintain high quality. The masses of village people were largely
ignored. With independence, the greater concern for common people
demanded a sharp shift in policy. As in all democratic political
structures, there is an egalitarian compulsion to distribute services
rather than restrict them to the elite. The votes are in the villages, and
politicians found it useful to make speeches promising free medical
care. Political realities then made it necessary for India to sacrifice
quality in a rapid expansion to obtain quantitative coverage. The
phenomenal speed with which the country was covered with primary
health centres is a truly remarkable achievement.
Doctors have always been the obvious symbols of health care.
An exaggerated mystique implies that increasing the number of doctors
will automatically lead to better health. Political compulsions led to
crash efforts to satiate rapidly the demand for doctors. It is, however,
not easy to turn off a manpower production flow, and an increasing
number of Indian states now face the impending dilemma of over
producing doctors—in the limited sense that money is not available to
absorb them into organized government services. Since the scope for
lucrative private practice is not inexhaustible, an increasing proportion
of doctors are escaping into the world market for physicians through
the much publicized brain drain.
Another political compulsion further tilts decisions to the
quantitative side of the production balance. The high prestige of
medicine leads children from elite families, and secondarily all
academically qualified candidates, to demand as a right the opportunity
to become doctors. The fascinating phenomenon of private medical
colleges being established with exorbitant capitation fees is now being
supplemented by straightforward political pressure to force continuing
expansion of government financed medical colleges. This pressure also
is directly counter to the planning priorities of meeting the service gap
in villages, since these students certainly do not picture their own
medical careers as being to serve rural areas. This continuing political
pressure comes at a time when the only thing that makes sense from
the planning point of view is to level off the production of doctors.
To offset the bulge at the top of the manpower hourglass, it is essential
that a massive concentration of educational effort be focussed on filling
out the thin neck of the hourglass to convert it into the desired
manpower pyramid by producing supporting personnel and auxiliaries
in much larger numbers than doctors.
In summary, then, a period of massive quantitative expansion of
medical education in the past two decades was probably inevitable. It
is now time for this curve to plateau. The emphasis must shift back to
qualitative considerations. But this requires a new definition of quality.
In the past, quality of care has been defined only in terms of
medical care for the individual. More and more knowledge, skill, and
sophisticated technology were applied to improving the care of specific
illnesses without regard to cost. By contrast, a modem definition of
good quality care for the community starts with recognition that the
goal must be adequate care for the whole group rather than excellent
care for the few. This immediately introduces a need for cost-benefit
judgements because resources will always be limited. The great
challenge is to learn how to identify those problems for which the most
can be done with the limited resources available.
When quality is defined in community terms, the location as well
as the content of medical education must be rethought. There is no
excuse for limiting practical training just to teaching hospitals. It is not
desirable for students to learn how to work only with elaborate
equipment, since the professional careers of most doctors will not
permit them access to such facilities ever again. Even more important
than the straightforward issue of learning inappropriate skills is the
more subtle psychological impact of teaching based exclusively on
hospitals. During the impressionable medical college years, the young
doctor has set before him a value system, role models, and professional
expectations; thereafter, he measures all his activities against the
original teaching hospital experience. A subconscious reflex judgement
leads to a downgrading of other types of practice. If the doctor
remembered only the intellectual and scientific atmosphere of the
teaching, hospital rather than the material environment, then this might
still be good. More often, however, his standard of judgement becomes
138
Doctors for the Villages
the physical plant, complicated technical equipment, and evidences of
affluence ostentatiously displayed by clinical professors.
The result is that most physicians then go through their profes
sional lives with a sense of failure because they have not met the
standards set by their professional role models. When tire gap between
the “ideal” and their own practical working situation is moderate, they
presumably experience a beneficial psychological stress which may be
a valuable source of professional stimulation. As in other stress
conditions, however, when tire gap between expectations and perform
ance is as great as in the reality of most medical practice situations
in India, the young doctor finds that he has little basis on which to
adapt to his field realities tire excellent techniques that he learned in
medical college. He just gives up because good quality seems impossible
and, therefore, irrelevant.
A practical solution would seem to be to distribute the practical
training over some combination of four levels of facilities. Certainly
some time in teaching hospitals is needed to provide understanding of
what is possible in quality care for tire seriously ill individual. Then a
period in a more average district hospital would fill the gap in relation
to the usual hospital care patterns. Thirdly, there is need for intensive
experience in a teaching health centre where community care is
demonstrated as it should be provided. Finally, some time in a more
average health centre would round out the student’s range of practical
experience. By being exposed to scientific and intellectual stimulation
and good care in all these situations, the young doctor will learn to
separate the realities of what is necessary for good care in the majority
of illnesses from the less essential extra refinements that have become
symbolic of the teaching hospital.
The basic philosophy represented by this new definition of a good
quality of community health care leads to the concept of a medical
college without walls. The community and its health facilities would
be as much a part of the medical college as hospitals and laboratories.
Following this broad review of implications for medical education, we
turn to some specific findings from this research.
Selection of Candidates
A major conclusion of this study is that in order to produce
doctors with a rural orientation it is necessary to select students who
A New Pattern of Rural Medical Education
139
have the best prospect of developing this quality. It will probably
never be possible for the medical college and internship experience by
itself to consistently ensure a rural orientation.
Interns from a rural background expressed greater interest in
primary health centre work than other interns. They also appreciated
the importance of subject matter relating to rural practice and by every
criterion measured they showed greater ability to profit from their
rural training. Similar but less clearcut results were observed in
students from poor families. To get rural doctors, then, a first step
is to create scholarships for worthy students from rural and poor
families so that their rural origin or financial status will not prevent
them from getting a medical education, but instead will open to them
an opportunity to obtain a good medical education.
In this study, it was possible to get direct and apparently
meaningful responses about the level of interest in rural health. Our
questionnaire approach would obviously not work as part of a selection
process because all students would soon recognize that statements
showing interest in rural service would increase their chance of
admission.
Innovations in admission procedures which get away from
standard examinations graded with pseudo-mathematical precision will,
of course, run into serious challenges because of possible distortions
and the inevitable accusations of favouritism. However, the assumption
that there is much significant association between “merit” and exam
ination results is patently fallacious.
As a more promising alternative, our research experience with the
Rural TAT suggests that it might be worth a trial as a selection
mechanism. Using the standard coding manual, rather accurate scoring
proved possible for characteristics defined as favourable responses to
villages (V+), and unfavourable responses to villages (V—■). Long
experience with TAT tests suggests that it is difficult for responses
to be faked except with a rather sophisticated understanding of the
psychological basis for the test.
One of the most definite conclusions of this research is that
greater opportunities in selection for medical education need to be
provided for rural and poor students. Since this requires general
recruiting, something should also be done to provide opportunities
for candidates who are not admitted to medical colleges. If an
adequate expansion of paramedical and auxiliary education is achieved
1-10
Doctors for the Villages
A New Pattern of Rural Medical Education
the same promotional effort could be used to attract candidates to the
whole range of positions in the manpower pyramid and to arrange a
flow upward within the system.
Undergraduate Medical Education
Courses during the medical college years should be designed
primarily to provide understanding and skills in the basic disciplines
of community medicine, while the rural internship will provide
opportunity to practice these skills. These undergraduate requirements
can be summarized as follows (Taylor 1970):
A.
Basic Sciences of Community Medicine
1.
Ecology
2.
Social Sciences, including health economics
and community organization
3.
Statistics
4. Epidemiology
5.
Demography
6. Genetics, Nutrition, and Child Growth
and Development
Applied Sciences of Community Medicine
1.
Administration of Health Care, and
Integration of Basic Health Services
2. Management of the Health Team
3. Community Disease Control Measures
(sanitation, vector control, community health
education, organization of programmes for
specific health services such as immunization
and nutrition
4. Family Planning
C.
Basic Changes in Attitudes and Values
1. Learning to rank priorities among health problems
and to concentrate resources on priority problems
2. Learning the doctor’s new role in the health team
To provide opportunities to practice basic skills such as epidemiological
survey techniques, health education, and the diagnosis and amelioration
141
of community problems, it is important to have a community
laboratory. For undergraduate teaching in the village setting we refer
to the study village as a laboratory rather than a field practice area,
because students should be learning specific skills and gaining under
standing rather than learning how to implement a general service
programme. It is especially important for students to learn to work
with families and neighbourhood groups. Observation units must be
small enough to be readily understood and analysed. It is better to
incorporate relevant experiences in a graded sequence throughout the
medical curriculum than to attempt to crowd them all into the
internship period.
General Organization of Rural Internships
The focus of this research project has been on the rural internship
because it provides the most important opportunity for practical
orientation to village work. During the medical college years students
usually visit villages only for an afternoon or a day. They are in groups.
If properly run, the experience can be sufficiently stimulating to be
interesting. During the internship, however, the young doctor should
actually live in the village. Village problems take on much more reality,
even though there is more chance for negative reactions.
A good internship in any subject should provide progressively
increasing responsibility under supervision. Too many internships fail
just because it is simpler to have interns observe than to have them
actually do the work.
Another general dictum is that there is no point in spending time
in the rural internship doing things that can be done more efficiently in
a hospital, such as clinical medicine. The time in rural communities is
precious because it is so hard to arrange. Transportation and logistics
limit the time available, but there are many valuable lessons that can be
learned only in the health centre and community.
In view of the multiple objectives and organizational possibilities
of rural internships, it seems worthwhile to summarize our present
thinking about educational objectives and activities based on this
research. Our ranking of activities is very different from the priorities
attached by the interns to a doctor’s health centre responsibilities
(Fig. 6.12).
142
Ductors for the Villages
(A general comment needs to be made about our internship data. We
have not reported individual medical college differences as part of our
research results nor related these to programme components in those
internships, although there might be much to be learned from such an
analysis. The numbers from some of the colleges were not large enough
for separate analysis. The main reason, however, is that we had
promised the medical colleges at the start that no mention would be
made of individual college differences because invidious comparisons
would be inevitable. We did give each college its own set of research
findings to be used to improve its own internship programme. To
provide descriptions of some workable programme alternatives that
have been tried, the college programmes have been described in
Chapter 3.)
Specific Objectives
Management of a comprehensive care team is a general skill that
can be learned only in a field practice area. Since it represents a
primary responsibility of health centre doctors, it probably deserves
top priority. Interns should be placed in working relationships with
other members of tire health team so they can learn the activities and
capabilities of other categories of personnel. Specific situations can be
set up which require the exercise of management skills.
Another important set of skills is community diagnosis. This
requires a working knowledge of field epidemiology and statistics.
The community physician must follow community rates and vital
statistics as carefully as a clinician observes temperature, pulse, and
laboratory findings. It is also important to learn practical and
simplified social science skills and principles because many community
problems relate to social variables more than biological causes. Some
experience with environmental sanitation is worthwhile, even if not
rated high by the interns.
Because flexibility is necessary in adapting a health service to local
needs, the health centre doctor must learn how to plan. One of the
most important steps in the planning process is to specify priorities.
This requires some mathematical calculations but even more necessary
is practice in balancing judgement to make appropriate cost-benefit
and cost-effectiveness decisions. Presumably by making analyses of
A New Pattern of Rural Medical Education
143
priorities as they relate to families and small groups, experience can be
gained that will prove useful in dealing with larger communities.
There are, of course, many other things that can profitably be
learned in the rural internship. Some experience in health centre
clinical work is desirable, especially since this is rated highest by the
interns. All clinical activities should demonstrate how the doctor and
his associates can use simplified procedures for diagnosis and treatment.
It is more important, however, that emphasis be placed on getting the
feel of how the doctor can support the auxiliaries who are responsible
for carrying out primary medical care, and how best to work within
the simple standing orders that provide adequate routine care for most
patients.
One thing rural internships should not do is to simply provide an
unsupervised chance to practice clinical medicine. The sad truth is that
in a village, interns can often do things they would never get a chance
to do in a hospital because there is no competition from the clinical
heirarchy above them. Most clinical experience can be gained more
usefully in hospital wards and outpatient departments.
Principles in the Organization of Rural Field Practice Areas
Our thinking about practical field training has changed consider
ably during this study. We are no longer satisfied with the idea that
a single village health centre can provide an adequate teaching base.
An area is needed where all the regional health service components
are functioning. Two major lessons have been learned about how
village services might be organized in such a demonstration area.
First, it is essential to have a genuine, working service. Too often
in the past we have merely tossed interns into a village to learn what
they could do on their own without any supporting services. This is
equivalent to sending students for clinical instructions into a large room
containing patients lying in beds with no supporting services. No one
would call such an arrangement a teaching hospital. Without nursing,
laboratory, X-ray, diet, and other supportive services, students would
learn little about modern medical care. Similarly, community care of
good quality requires a full health team within which the young doctor
can work in order to learn how a programme should be run.
Furthermore, there has been too much insistence by some that the
teaching health centre should be kept at the functional and financial
level of an average PHC. As indicated earlier, interns need to have
Doctors for the Villages
1-1-1
assurance that the village health problems are not insoluble. Then they
should also spend some time in an average primary health centre to
learn how optimum methods can be adapted.
Tile second major consideration is that it is important to get
respected clinicians involved in both service and research in the field
practice area. A major psychological need is to show young doctors
that rural work is respectable. Nothing will add respectability as much
as seeing clinical professors periodically participating in health centre
activities. The simplest thing to arrange, usually, is a weekly clinic
which can be used for teaching. Even more useful is to get clinical
faculty involved in joint clinical-epidemiological research in which
students can participate. This has tire advantage that clinicians will see
that they, too, can get something out of the experience.
The Qualities of Field Teachers
Field teaching will change orientation and motivation only if
teachers can create an atmosphere of excitement and challenge. It is
of primary importance that they really know the village through
prolonged personal involvement. A problem in finding staff for
teaching health centres has been that those who volunteer tend to
get stuck in the village just like PHC doctors. A more equitable
arrangement would be to require a rotation of service from all the
community medical staff.
The most important personal characteristic to ensure good
teaching is enthusiasm. This is especially true where difficult field
work makes it all too easy for teachers to evade difficult tasks under
rigorous conditions by telling the interns to do the work and not
participate themselves. The teacher must believe in village work and be
optimistic about the chance for change. He must like village people.
His interests should be broad enough to cover a wide range of rural
development subjects, such as agriculture and anthropology. Enthu
siasm must be blended with concern to produce a service motivation
that is contagious.
Relation of Community Medicine Teaching in Medical Schools to
Graduate Education in Public Health
A final comment must be made on the much discussed subject of
A New Pattern of Rural Medical Education
145
the relative roles of community medicine teaching in medical schools
and graduate education in public health. An artificial confrontation
often develops between the two educational activities which is
unfortunate, irrelevant and diversionary. Some international consult
ants continue to push the idea that medical schools should absorb
schools of public health. A related argument is that community
teaching in all departments of a medical school will eventually make
departments of community medicine unnecessary. The fallacies in
these points of view are numerous but they are rooted in the supercil
ious attitude that only doctors can cope with health concerns because
the problems are fundamentally clinical.
Public health includes a wide range of professionals other than
doctors — i.e., sanitary engineers, statisticians, nutritionists, social
scientists, economists, planners, administrators, and several kinds of
biological scientists. It is not just another medical specialty such as
surgery or radiology; therefore, graduate training in public health
cannot be treated as just another process of getting a group of
doctors through specialty training. There are great benefits in
providing graduate training for this multi-disciplinary group of public
health specialists, including doctors, in a shared environment. Where
schools of public health are run as departments of medical schools,
there is an inevitable focussing on clinical preventive medicine and
medical specialties.
The argument that departments of community medicine should
eventually be eliminated as their work is absorbed into clinical
departments is even more damaging to a strong community emphasis.
An equivalent argument would be that since all doctors should know
pathology and pharmacology those departments should also be
absorbed by clinical departments. We have repeatedly stressed in
this volume the necessity for clinical departments to be actively
involved, especially in teaching and research in the field practice area.
This requires constant stimulation and coordination provided by
specialists in community medicine, otherwise long term interest and
continuity is extremely uncertain. The Johns Hopkins Medical
School provides an example of the almost total withering away of
an excellent teaching programme in preventive medicine after the
department of preventive medicine was abolished in 1947, making it
146
Doctors for the Villages
difficult for the school of public health to pick up the responsibility
because there was no focus in the medical school with which to work.
The optimum is to have a department of community medicine in the
medical school and a separate school of public health but no arrange
ment is automatically fast or easy. The old proverb applies here,
“What is everybody's business, soon becomes no one’s business.”
JO
Findings and Recommendations
of the 4 th Narangwal Conference
No aspect of our research was as important as the consistent effort to
get active participation of leaders in medical education and health '
administration. The most fruitful means of ensuring this relationship
was through the annual Narangwal conferences.
At each conference, the information that had been accumulated
up to that time was presented as raw data for interpretation to forty
to sixty experts from medical colleges and health services. They were
in a far better position than the research staff to make realistic
interpretations of the findings since they knew what recommendations
could be implemented and how.
The Fourth Narangwal Conference was held in November, 1966,
just before the Third World Conference on Medical Education in New
Delhi. In addition to Indian medical leaders, this meeting brought
together an outstanding group of international experts. Part of the
data presented in this volume was available for that meeting.
The conference identified the findings which follow as having
highest priority in practical programmes. They also agreed after
intensive discussion on a series of recommendations. Considerable
progress has already been made in implementing some of these
recommendations, and at least two conferences on rural medical
education organized in New Delhi by the Indian Ministry of Health
have reviewed these same matters since that time. Since the recom
mendations which follow were developed by Indian leaders, we present
them here as the best judgement available about what should and can
be done to improve medical education and health services.
Doctors for the Villages
148
I - THE RURAL INTERN
Findings and Recommendations
3
1-
Facilities for higher secondary and pre-university scientific
preparation for medical college admission now concentrated
in large urban areas should also be located in rural towns.
4
1-
A programme of vocational guidance and counselling about
rural medical service should be focussed in higher secondary
schools, especially those in the rural areas. This guidance
should include reference to other opportunities for service
as health personnel for those who do not care to or do not
qualify to become physicians.
1-5
All of the above recruitment efforts to attract the best rural
students to the health professions should be widely
publicized.
1-6
Ways should be explored to give preference in selection for
medical education to candidates with a rural background or
those from lower economic groups without actually fixing
a quota or reserving seats.
1-7
Examinations for entry into medical college should include
assessment of rural knowledge and rural interest with appro
priate weight being given to those subjects in the eventual
selection of students.
1-8
Efforts should be made to devise appropriate tests to identify
willingness and aptitude for practice in rural areas.
Findings:
A
I-
Doctors coming from a rural background expressed greater
preference for service in rural areas than those from an urban
background.
LB
Doctors from a rural background considered themselves
better prepared for rural work when they entered the rural
field experience than those with urban background.
C
I-
Doctors from a rural background said they profited more
from the rural training than urban doctors.
D
I-
Doctors from lower economic groups expressed greater
preference for service in rural areas than those from upper
economic groups.
E
1-
Doctors who expressed interest in rural service considered
themselves better prepared for rural work when they entered
rural field experience than those with less interest, and they
profited more from the experience.
F
I-
Doctors who expressed an interest in rural service also had a
greater appreciation of issues related to community service
and a greater social concern than those with less interest.
II
Recommendations:
1
1-
Special measures should be used to attract rural students to
apply for admission to medical colleges.
2
1-
Liberal stipends should be made available to students from
lower economic groups, especially those from rural areas.
149
- THE PRIMARY HEALTH CENTRE
Findings;
A
II-
Favourable factors influencing attraction to rural service are
those associated with the challenge of comprehensive pro
fessional work and independent responsibility in situations
of obvious need.
150
Doctors for the Villages
B
II-
The most important unfavourable factors which deter young
doctors from choosing rural service are deficiencies in pro
fessional working conditions and opportunities, with the
highest priority being given to lack of drugs, supplies, and
equipment and the lack of opportunities for augmenting
professional preparation and continuing education.
C
II-
Among the unfavourable factors affecting personal living,
the lack of educational facilities for children and isolation
from urban facilities was more important than pay or
housing.
D
II-
Interns do not recognize the health care problems arising
from the heavy curative load carried by many primary health
centres.
Recommendations:
l
II-
Improvement of primary health centres is a high priority
need in order to make them satisfactory places for doctors
to work.
2
II-
The provision of drugs, supplies, and equipment should be
commensurate with the service requirements of primary
health centres. A standardized list of basic drugs should
always be in stock and should periodically be reviewed in
order to improve logistics and efficient utilization.
3
II-
To make more efficient use of the time and skill of the
health centre physician, his major responsibility should be
recognized to be the organization and leadership of a
health team of appropriate paramedical personnel. Spec
ially trained medical assistants should be provided to take
care of patients under the supervision of the physician.
4
II-
Action-research trials should be conducted on tire role of
paramedical workers in initial screening and simple care
of the large number of minor illnesses which now over
whelm tire resources of many primary health centres.
151
Findings and Recommendations
Such activities
under the auspices of medical college
teaching centres would add professional respectability to
efforts to improve primary medical care.
U-5
Clear lines of authority commensurate with responsibility
should be established at all administrative levels (PHC, block,
district and directorate). Direct channels of communication
should be kept open—both administrative and technical. The
medical officer should be in administrative control of all the
staff under him. He must, however, coordinate his work
with the block development officer. Improved orientation
and training of both medical officers and block development
officers are necessary for better advancement of their mutual
interests.
II-6
Arrangements for statistical assistants and clerical assistants
to take care of routine reports, vital statistics, indents, stores
and accounts should be rapidly implemented. Forms and
procedures should be simplified and standardized. There
should also be a standard and simplified nomenclature of
diseases.
U-7
Transportation facilities should be provided to meet the
professional requirements of physicians and health centre
staff.
II-8
Primary health centres should be located in situations where
they are easily accessible to the public and to general
transportation facilities.
n-9
The professional competence of health centre physicians
must be upgraded, with particular emphasis on the new
duties being expected of them.
11-10
Medical colleges should assume the responsibility for main
taining contact with doctors at primary health centres in
adjacent regions. Where possible, professional stimulation
and guidance should be
regular m-service
J
326, V Main, I Block
'
koramongala
8'3n9sl0f“-560034
—
154
Doctors for the Villages
25
11-
Present regulations should be modified to allow women
doctors to work on a part-time basis if, due to marriage, this
is the only condition under which they can be available.
They will be especially useful in family planning services.
Findings and Recommendations
d.
F
III-
Ill
- THE EDUCATIONAL PROGRAMME IN
RURAL TEACHING CENTRES
Findings:
II1-A
Field experience in rural programmes had a favourable
influence on interns’ general attitude towards village people
and work. Apparent negative attitudes might actually be
better interpreted as being in the direction of developing a
realistic understanding.
B
III-
A marked ambivalence was found among interns ranging
from a lack of confidence in their professional ability to a
desire for the challenge of independent responsibility.
C
III-
The educational objectives of the rural internship are poorly
defined. They are especially unclear and poorly communi
cated to interns who reported that their activities during
internship were, in general, less worthwhile than they had
anticipated.
D
III-
Activities in tire rural field experience which seemed most
worthwhile to interns were learning to deal with:
a. practical health problems
b. villagers
c. colleagues
d. socio-economic factors in disease
E
III-
Interns’ suggestions for improving the teaching health centre
activities were ranked in the following order:
a. improvement of their own living conditions
b. improved equipment and supplies
c. better planning and organization of the educational
programme
155
more emphasis on preventive work which was a need
especially recognized by those interns most interested in
rural service
Because of the uniformly high respect for clinical teachers,
there are many indications that the involvement of clinicians
in rural activities would have a major impact on attitudes
toward and preparation for rural service.
Recommendations:
l
III-
A fundamental need is to improve the departments of social
and preventive medicine in their competence to deal with
rural problems. The name of the department of social and
preventive medicine should be changed to the department of
family and community medicine. The importance of the
community approach and of family planning should be
emphasized.
2
III-
In the selection of teachers, at least two years of rural
experience in community medicine, with administrative
responsibility, should be required. This is in addition to a
post-graduate degree in public health. All teachers in the
department should periodically spend some time in a rural
health centre. They should be given special incentives and
inducement to reside in the field training centre.
3
III-
Innovations in the present rural internship programmes
should be continued, to make the experience more educa
tional and stimulating. The objectives of the rural internship
programme should be clearly stated and communicated to
the interns as they start their field work.
III-4
Rural internship programmes with emphasis on individual,
family, and community health should require at least three
months of working and living in rural health centres. They
should include total exposure to health problems, learning
to work with paramedical personnel, active involvement in
administration, and independent responsibility under super-
156
Doctors for the Villages
vision for a specific small community unit. Some experience
has shown the particular value of giving small groups of
interns responsibility for the comprehensive health care of a
specific area or village (two interns for up to 1000 popula
tion) which can be considered their village ward for
community-side teaching.
III-5
I1I-6
III-7
For improved learning about community medicine, medical
colleges should assume responsibility for the administration
of the organized health and medical services of a geographical
area, up to a whole district in size. Both rural and urban
communities should be included. This area should be
considered both a laboratory and a ward for teaching
comprehensive care and community medicine. As a mini
mum, tire area should include one rural teaching centre and
a network of subcentres covering a community development
block. For adequate community-side teaching, and to avoid
crowding of interns, more than one teaching health centre
would be desirable. Most appropriate is the concept of a
medical college without walls, with all district health facilities
included in the responsibility of the medical faculty. At
least one member of the faculty should reside in the training
area to supervise and organize tire training of students and
interns.
To provide an optimum base for rural field experience, there
should be a major reorientation of teaching health centres.
The main requirement is that they should provide active
services that reach right out to village homes from subcentres.
This requires a full staff of upgraded auxiliary nurse-midwives
in sufficient numbers so that each will have to cover no more
than 5,000 population.
Accommodations should be provided for the students, the
staff, and the visiting staff in the main centre and sub-centres.
Library facilities should be available in the field training
centre and the whole atmosphere should convey the
academic environment of an educational institution.
Findings and Recommendations
167
HI-8
Health centre facilities and activities should include a
sufficient range of qualitative variety to bridge the present
gap between the sophistication of the teaching hospital and
the actualities of the working conditions faced by most
Indian doctors. Some teaching health centres should be as
different
from service health centres as the teaching
hospitals are from service hospitals; they need additional
staff and facilities. But other teaching health centres
should demonstrate that good work can be done with a bare
minimum of facilities and staff.
ni-9
There should be an ample budget for administration and for
improvement in facilities, services, teaching, and research.
The teaching health centres should be administratively part
of the medical college. Where health centres must be used
which are not administratively part of the medical college,
additional staff, finances, and equipment should be provided
by the college. In either case, it is essential that in order to
facilitate smooth working relationships there be a joint board
or committee with representation from the medical college,
the local government, and most importantly, the community.
ni-io
The block development staff should be included in the
teaching programme of the field teaching area and arrange
ments should be made for interns to attend block meetings.
ni-ii
It is desirable to provide a housemanship or residency beyond
the internship in family and community medicine as is done
in the clinical fields. This should then lead to full qualifi
cation as a specialist in this area to develop individuals who
can bridge the present gap between curative medicine and
public health.
III-12
Within the one-year rotating internship there should also be
better use of the rest of the internship period to provide
interns with more responsibility and opportunity to learn.
The nine months of the clinical internship period could be
spent in small or medium sized hospitals, preferably in rural
158
Doctors for the Villages
Findings and Recommendations
areas. Selection of these hospitals and supervision of the
programme should be the responsibility of a committee
consisting of members from the faculty, the local health
officials, and the hospitals, with a member of the Department
of Family and Community Health acting as coordinator.
111-13
HI-14
III-15
ni-16
Since much of a doctor’s understanding, skills, and attitudes
are developed during undergraduate training, preparation for
rural experience should start during the undergraduate years.
Emphasis on the family and community aspects of medicine
should begin in the first medical year, with''graded exposure
to specific aspects of rural health needs, starting with
environmental health and progressing to teaching which is
actively integrated with clinical departments. The health
centre clinics can be organized as extended sections of the
outpatient department.
During their undergraduate training, students should be fully
familiarized with the working of well-run primary health
centres in which auxiliaries carry out a whole range of
appropriate curative and preventive functions. It is parti
cularly essential that they leam how good administrative
arrangements can cope with a heavy curative load without
the doctor having to feel compulsive about seeing every
patient on every visit.
Examinations in clinical subjects should include assessment
of knowledge of clinical preventive measures. Because family
and community medicine involves so much more, however, a
separate examination in preventive and social medicine
should be compulsory and should be given emphasis equal to
examinations in clinical subjects. The recommended curricu
lum changes will have little meaning unless this is done.
It is increasingly apparent that in order to achieve a
maximum impact on young doctors, it will be desirable to
involve all the faculty, especially clinical specialists, in the
159
field experience. The curriculum committee should ensure
the introduction of community and rural material in all
courses. Teaching, research, and service in the medical
college health centre should be the responsibility of all
faculty members and not only of the department of family
and community medicine. In the teaching of obstetrics,
it is desirable that at least ten deliveries be conducted by the
student under domiciliary conditions. A similar number of
lUCD’s should be inserted in the family planning clinics of
the health centres.
HI-17
The importance of rural medicine to India dictates that all
teachers in medical colleges should have had at least one year
of rural experience. Present teachers in clinical departments
who have not had this experience should spend a period of
three to six months in a PHC or small rural hospital or should
actively assume responsibility for working with the staff of
a primary health centre in a district associated with the
medical college.
III-18
Without the interest and active support of the dean or
principal, none of the above measures can be implemented.
Consideration should be given to appointing an administra
tive officer, equal in status to the superintendent of the
teaching hospital, to be responsible for rural services,
especially if the medical college assumes responsibility for
the whole district.
IV
- OBLIGATORY SERVICE
Findings:
A
IV-
Only five percent of interns strongly indicated that they
would leave medical practice rather than go into rural service,
and twenty-eight percent strongly agreed with the statement
that they would serve in rural areas only if it were legally
required.
Doctors for the Villages
160
Comment: Few topics relating to the medical services of
India generate as strong or as sharp a division of opinion as the question
of whether all doctors should be required to serve two or more years
as needed by the Government. The dilemma is clearly one of balancing
the rights of society against the rights of doctors. The only rational
approach for this conference appeared to be to consider alternative
approaches.
In India, decisions about obligatory service for doctors are
included in the responsibilities delegated to each state. Individual states
are at different stages of evolution of health services and have widely
different manpower situations. Where obligatory service is already in
effect, it would be gratuitous to say that the requirement had been
imposed prematurely. In fact, this provides an ideal situation to
observe the strengths and weaknesses of this alternative as carefully
and objectively as though this were an experiment.
In planning a solution to the rural problem, a strong con
sensus of the conference was that great damage would be done if a
rural requirement of two to three years were considered a substitute
for the general improvements in conditions of service and personal
incentives outlined in these recommendations. Coerced and unhappy
doctors will do little good in a PHC. A total package of improvements
is envisaged in which particular stress will be placed on professional
support of the health centre physician, which is most important for
reluctant physicians. At present, there is at least some selection of
doctors for a modicum of interest in rural service which tends to lead
to better work.
Findings and Recommendations
3
IV-
The decision about obligatory service should continue to
depend on local considerations in each state.
2
IV-
States which have already decided on obligatory service
should concentrate particularly on providing incentives
which have been outlined under recommendations II-l to
11-25.
States which do not have compulsory service should con
centrate first on providing the incentives of both better
living and professional working conditions. If these measures
do not meet the manpower needs of rural health centres,
then obligatory service should be imposed.
V
- GENERAL RECOMMENDATIONS
l
V-
There is need for further study and research to determine
if students with a rural or lower socio-economic background
do indeed return to rural areas for practice, when appropriate
incentives are provided, more frequently than do students
from urban areas.
2
V-
National institutions like the National Institute of Health
Administration and Education should establish a chair in
family and community medicine so that senior faculty from
medical colleges can spend a year on deputation to undertake
studies of means by which the services provided at primary
health centres can be strengthened.
3
V-
The Central Government is urged to sponsor a bold and in
novative approach to experimentation in medical education.
In an appropriately chosen rural district, a medical college
without walls should be established. Instead of the tre
mendous present financial cost in the armamentarium of
highly refined subspecialties, the faculty should be mainly
composed of generalists (general surgeons, general medical
specialists). Seminars could be held on wheels, in jeeps and
vans going to and from field situations. Imaginative experi
mentation should be encouraged in streamlining the learning
process and discarding present irrelevancies.
4
V-
Operations research on rural health programmes should be
undertaken by medical colleges through departments of
family and community medicine. Particularly needed is
attention to the many possibilities of mobilizing local
Recommendations:
1
IV-
161
162
Doctors for the Villages
community support for health services instead of expecting
government funds to provide total support. The Indian
Council of Medical Research and other agencies of the
Government of India should coordinate these research studies
and strengthen institutional capacities in the disciplines
required.
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Merton, R.K.; Readers, G.G. and Kendall, P.L., eds. 1957. The
Student Physician: Introductory Studies in the Sociology of
.Medical Education. Cambridge: Harvard University Press.
Roemer, M.I. 1959. Social Science and Organized Health Services.
Human Organization 18 (2):75-77.
Mumford, E. 1970. Interns: From Students to Physicians. Cambridge:
Harvard University Press.
Second World Conference on Medical Education 1961. Medicine: A
Lifelong Study, in Proceedings of the Second World Conference
on Medical Education, Chicago, 1959. New York: World
Medical Association.
Punjab Directorate of Health and Family Planning 1973. Functional
Analysis of Punjab Health Services: A Preliminary Assessment
of the Intensive Multipurpose Village Health Service Campaign
in Two Blocks of Sangrur District - Report of the Baseline
Survey. Chandigarh: Punjab Directorate of Health and Family
Planning, Government Press.
Omran, A.R. 1971. The Health Theme in Family Planning. University
of North Carolina Population Center Monograph 16. Chapel
Hill: University of North Carolina Press.
Rao, K.N. 1973. Internship Programme. Indian Journal of Medical
Education 12(1 and 2), January=June.
Reader, G.G.; Goss, M.E.W. and Korsch, B., eds. 1967. Comprehensive
Medical Care and Teaching: A Report on the New York
Hospital—Cornell Medical Center Program. New York: Cornell
University Press.
Reinke, W.A.; Taylor, C.E. and Parker, R.L. 1973. Functional Analysis
of Health Needs and Services, in Uses of Epidemiology in
Planning Health Services, Vol. II, Proceedings of the Sixth
International Scientific Meeting, Primosten, Yugoslavia, 1971.
Belgrade: Savremena Administracija, published for the Inter
national Epidemiological Association.
| Reinke, W.A.; Parker, R.L.; Alexander, C.A. and Taylor, C.E. 1976.
Functional Analysis of Health Needs and Services. New Delhi:
Asia Publishing House.
Snoke, P.S. and Weinerman, E.R. 1965. Comprehensive Care Programs
in University Medical Centers. Journal of Medical Education
(US) 40:625-657.
Takulia, H.S.; Taylor, C.E.; Sangal, S.P. and Alter, J.D. 1967. The ■
Health Center Doctor in India. Baltimore: Johns Hopkins
Press.
Taylor, C.E. 1955. The Teaching of Preventive Medicine in India.
Journal of the Indian Medical Association 24:591-596.
Taylor, C.E. 1956. India Modernizes Her Medical Education. New
England Journal of Medicine 255:897-899.
Taylor, C.E. 1965.
475-486.
Health and Population. Foreign Affairs April
Taylor, C.E. 1970. Community Medicine and Medical Education
Indian Journal of Medical Education 9 (6 and 7) June-July.
Taylor, C.E. 1970. Population Trends in an Indian Village. Scientific
American 223:106-114.
Taylor, C.E. and Hall, M.F. 1967. Health, Population and Economic
Development. Science 157:651-657.
Taylor, C.E.; Dirican, R. and Deuschle, K.W. 1968. Health Manpower
Planning in Turkey: An International Research Case Study.
Baltimore: Johns Hopkins Press.
168
/
Doctors for the Villages
Taylor, C.E. et al 1973. The Narangwal Experiment on Health and
Family Planning. Paper presented at the 9th International
Congress on Tropical Medicine and Malaria, October, 1973,
Athens, Greece.
/ Taylor, C.E. and Takulia, H.S. 1971. Integration of Health and
Family Planning in Village Sub-Centres: Report on the Fifth
Narangwal Conference, November, 1970. Narangwal (India):
Rural Health Research Centre.
Third World Conference on Medical Education, New Delhi 1966, 1968.
Medical Education in the Service of Mankind. Proceedings of
the Third World Conference on Medical Education, New Delhi,
1966. Indian Journal of Medical Education (Special Issue)
7 (3) May.
Tampi, N.K. 1954. Social and Preventive Medicine in the Medical
Curriculum. Journal of the Indian Medical Association 23:
338-339.
i Uberoi, I.S.; Laliberte, D.; DeSweemer, C.; Masih, N.; Kielmann, A.;
Vohra, S.; Forman, A. and Bohnert, S. 1974. Child Health
Care in Rural Areas: A Manual for Auxiliary Nurse Midwives.
New Delhi: Asia Publishing House.
Van Zile Hyde, H., ed. 1966. Manpower: For the World’s Health.
Report on the 1966 Institute on International Medical Educa
tion. Evanston: Association of American Medical Colleges.
Vemey, R.E., ed. 1957. The Student Life: The Philosophy of Sir
William Osler. Edinburgh: E.S. Livingstone, Ltd.
Weinerman, E.R. 1966. Research Into the Organization of Medical
Practice. Milbank Memorial Fund Quarterly 44 (2):104-145.
Wiser, C. and Wiser, W.H. 1946.
Friendship Press.
Behind Mud Walls.
New York:
Bibliography
169
WHO 1970. Health Aspects of Family Planning. WHO Technical
Report Series No. 422. Geneva: World Health Organization.
Zola, I.K. 1963.
Problems of Diagnosis and Patient Care: The
Interplay of Patient, Physician and Clinical Organization.
Journal of Medical Organization 38 (10):829-838.
j
Appendix
171
Hypotheses Defined by Narangwal Conference
But Not Tested in the Study
Appendix
Page
1.
Interns are less likely to accept rural service if their parents
value most highly:
a. private practice in the home community.
b. the job security of government service.
c. the prestige of an academic appointment.
'2.
Interns will be more attracted to rural health services if they
do not feel superior to villagers.
3.
Interns will be more likely to react favourably to rural health
service if:
a. instructors are dedicated and enthusiastic.
b. instructors are well informed about village life and are
sympathetic to village people.
c. instructors know their subject and are able to communicate
well.
d. there is good cooperation between the health centre and the
other official and non-official agencies in the area.
e. the teaching health centre staff works as a team.
4.
Medical students with the best academic record in medical
college will be unlikely to enter rural health services because
of lack of opportunities for advanced post-graduate course work.
5.
Women interns are less attracted to village service than men
because they expect to marry into the social elite of the cities.
6.
Wives of doctors are less willing than their husbands to live
in villages.
7.
The relationship between rural health centres and villagers will be
better if:
a. the villagers are sufficiently familiar with scientific medicine
to have lost some of their cultural blocks but not so sophisti
cated as to demand facilities beyond the capacity of the
health centre.
171
Hypothesis
Forms for Battery of Tests Used in Field Survey
Identification Sheet
General Background Information
173
Form I
Rural Thematic Apperception Test
174
Form II
Questionnaire on Professional Matters
181
Form III
Questionnaire on Rural Programme
187
Form IV
Story Completion Test
193
Daily Log
Interns' Daily Log of Activities
195
Supervisor’s
Check List
Check List for Performance of Interns
196
172
Doctors for the Villages
b.
c.
d.
e.
f.
g.
h.
8.
the villagers recognize the effectiveness of curative services
provided by the health centre.
the villagers have an understanding of the need for preventive
services.
the villagers participate directly in the financial and work
management of the health centre.
tire health centre staff is not identified with village factions.
the villagers appreciate that interns have official status in
the health centre hierarchy.
tile villagers understand that rotation of interns need not
affect the service provided.
the villagers recognize the practical value to them of surveys
and other research activities.
Health centres which are an integral part of the medical college
rather than a sendee unit of the government health service will
tend to provide better instruction to interns because:
a.
the staff are professional teachers.
b. there is more administrative flexibility.
c. there is more continuity of teaching.
d. medical college specialists can participate in teaching.
173
Appendix
CODE NO_.
CONFIDENTIAL
BUBAL HEALTH BE8EABCH PROJECT
IDENTIFICATION SHEET
9.
Father's or Guardian's
approx Monthly Income
10 1 Religion :
10.2
11.
HinduQ
Caste
upto Rs. 200
Rs 1001-300U
SikhQ
MuslimQ
Village
11.1
Previous Residence
Rs. 201-500
Rs. 501-1000
Above Rs. 8000
ChristianQ
9.0
10.1
Other Specify.
Town
Less than 10,000
11.2
Approximate No. of
years.
>oa
City
11.3
11.3
How many times has your home been moved from one place to another ?,
Any other relatives who are in health work?
Yea
No
Specify, what and work ?
—
....
>ot^*r P°ll*n8a *n internship/housemanship have you done?
Medicine
Surgery
Gyn. & Ob
Other Specify.
IS. Are you under contract for a specified type or period of service ?
YesQ
NoQ
With whom.................. Period.....
18, How often have you visited a village ?
13.
In medical course 1
>3.1
13.3
13J
Earlier 2
Regularly
133
Occasionally
15.3
Once or Twice
Never
RURAL HEALTH RESEARCH PROJECT
FORM I
PLEASE READ THE FOLLOWING INSTRUCTION CAREFULLY
On the following pages you are to write out some brief stories that you make up on your own. There
is a series of pictures at which you can look and around which you build your stories. k ou should look at
the picture briefly (about half a minute), and then tum die page.
On the neat page alter each picture, you are
to write a story suggested by the picture (about 150 words—roughly a page in long hand.) You will have six
minutes for each story.
At the top of each page there are some guide questions for your convenience. They will help you to
cover all the elements of a story plot.
However, your stories should be continuous and not just a set of
answers to these questions.
There are no right or wrong stories. In fact, any kind of story is alright. You have a chance to
show how quickly you can imagine and write a story. Your stories should be interesting and dramatic; they
should indicate your understanding of the situation involved
••LEASE DO NOT TURN TO THE NEXT PAOE TILL YOU ARC RCQUCBTCO
1.
2.
3.
4.
What is happening 5 Who are the people in the picture ?
What has led to the situation depicted ?
What do the different people shown in the picture want ?
What do you think is going to happen ’
lull Iook 11 the picture briefly (about 30 tecondt). turn the page and write out the story It suggests
176
Doctors for the Villages
Appendix
177
Juit look at th* picture briefly (about 30 lecondi), turn th* page and writ* out th* itory It lugguti
Jun look at th* picture briefly (about 30 lecondi). turn th* pig* and write out th* itory It tuggeiti
Juit look at th* picture briefly (about 30 lecondi). turn th* page and writ* out th* itory It luggeitt
Juit look at th* picture briefly (about 30 lecondi), turn th* page end writ* out th* itory It tuggetu
180
Doctors for the Villages
181
Appendix
Used Before and After Internship
CONFIDENTIAL
Coda No
RURAL
HEALTH RESEARCH
Form II
PROJECT
Date.
1.
We would like to know your own personal preference among the medical specialities lilted beJow.
Please check (V) one block opposite each speciality indicating the extent of your own Interest la that speciality
Not
Interested
(1)
Speciality
I.I
Slightly
Interested
(»)
•
General Practice
1.2 Internal Medicine
1.3 Obstetrics and Gynae
1.4 Opthalmology
Jun look it the picture briefly (sbout JO lecondi). turn the page and write out the story It suggests
1 5 Pediatrics
1.6 Pre-clinical sciences
1.7 Preventive & Social Medicine
.'in medical college)
1.8 Public Health (services)
1.0 Surgery
For OHIo.
Only
Form II
Date
—
Name .
Ago
).u look «ch. piciuc. brlJI, (.bout »t.co.d.1. tun. th. p4. »d writ, our th. nor, It tutl..u
........ Sex
•.
Medical Collate.
Moderately
Interested
(8)
Very
Interested
(4)
Code
Doctors for the Villages
182
Appendix
3.
1 Luted below are variooa types of professional activities.
Please check (y*) one block opoosite each indicating the extent, to which, you personally ted attracted
by that type of professional activity as a career choice.
Not
Interested
(I)
Activity
11
AdminUtrative positions in
health and hospital services
Urban
2.4 General private practice
2.6
Moderately
Interested
(3)
Greatly
Interested
How important to you are the following (acton In choosing your career ?
appropriate columns below.
Factors
Code
(4)
Rural
Service in Private Hospitals
including religious institutions
Slightly
important
(21
3 I National Needs
33
Nearness to home
34
Prestige
3.5 Intellectual satUfaction
2.6 Research
3.6 Influence of teachers
2.7 Service in Armed Forces
8.7 Financial Remuneration
2.8 Primary Health Center
3.8 Job Security
19 Speciality, (Private)
3.9 Specified hours of work
2.10 Teaching
3.10
Leisure opportunities
3.11
Humanitarian and’religious
motivation
i
For Office Use Only
Not
important
(1)
3.2 Family opinion including parents,
spouse and close relations
12 Government Hospitals
2.3 General private practice
Slightly
Interested
(2)
183
3.12 Job Opportunities
For Office Use Only
•
Moderately
important
(3)
Please check (V) in
Very
important
<4)
Code
Doctors for the Villages
186
7.
We would like to hare your present estimate of the conditions under which you would be willing to
serve in a primary health center.
Please check (vO one block opposite each of the following statements indicating the extent to
which you agree or disagree with the statement.
Conditions
Disagree
(1)
7.1
Partially
Disagree
(2>
Partially
Agree
(3)
Agree
Questions 13 and 14 Used Only After Internship
Remainder Used Both Before and After Internship
CODE NO
CONFIDENTIAL
«)
RURAL
HEALTH
I would leave medical practice rather than
go to rural areas.
RESEARCH PROJECT
Form III
Date..
...............
8. Listed below are a number of factors which may Influence favourably the way yon feel about
serving in a primary health center in a rural area, (not Teaching Health Canter)
Please indicate how important these factors seem to you by checking (V) one of the blocks opposite
each Hem.
7 2 1 would accept a primary health center iob
only if my family were in urgent need of
financial help.
7.3 I would go only if legally required for oca
or two years before registration.
7.4
Code
187
Appendix
Not
important
tir
Factors
I would work in a primary health canter
only If I cannot find work elsewhere.
7 5 I would work in a primary health center if
thia was the only way of advancement
In government service.
8.1
Combining preventive and curative
services for individuals and families.
8.2
Service to particularly
needy
people
Opportunity for meeting unpiedlct*
able medical problems.
83
7.6 I would work under present conditions if I
knew I would not be stuck in village for Ide.
84
Helping to meet the national need.
8.5
Having administrative conttol over
technical work and personnel.
86
Chance to organise health service
lor a large group of people.
7.9 I would go if a liberal rural allowance and
provision for personal comforts were provi
ded but without significant improvement in
present profcasioosl opportunities.
87
Opportunity to study a community
as a whole.
7.1U I would go If facilities for maintaining good
quality professional standards were provided
and without particular regard for improved
living conditions.
89
7.11 I am willing to sacrifice both personal and
professional considaations indefinitely.
8.11 High position in village society.
7.7 I would go only if permitted to live in a
nearby city.
7-8 I would go if there was some improvement
in both professional standards tod living
coedition*.
Slightly
Important
(21
Moderately
important
(31
Vay
important
«)
Code
88
Spiritual and humanitarian motiva*
tion.
Being able to make your own
schedule.
8.IU Having independent responsibility
for diagnosis and treatment.
8.12 Medical Care.
Foe Office Um Only
7.12 Do you think you might change your
opinion if you knew more about primary
health center work ?
7.13 Please give the number of the one statement
above which moat nearly represents the
conditions under which you would go into
rural health work.
For Office use Only.
Yes.
No.
7.12
7.13
Cod. No
Form HI
Date
........ ..........
Name
Aga
-..........................................................
Sax
-
...Medical Collage
.............
190
11.
Doctors for the Villages
We would like to know wme of your impressions about village people. Listed below are some paired
opposite terms that might be used to describe acy person or group Think of villagers as a group
rather than of any one villager you may know. There are no right or wrong answers.
Please give us your general impressions of village people by checking an appropriate space between each
pair. For example .
A
B
C
D
191
Appendix
IX We would appreciate a frank statement from you about the activities you will engage in during your
rural Internsnip/houscmanship.
Check (\Z one block opposite each item. We want your opinionabout how worthwhile you think these
activities are going to be.
Kind
Unkind
If you think villagers generally are very kind, you would check space A, if you think they are some
what kind you would check B, if you think they are a little unkind you would check C, and if you
think they are unkind then check (v'j D. We would like to have your impiession even if you arc not
Not worth while
Activities
(»
Evaluation
Moderately
worth while
(»
Worth while
W
12.1 Out-patient care
12.2 In-patient care
Preventive services for individual
patients
12 4 Community Health Services
including health education
12.3
12 5
Family care
1X6
Field survey
12 7
Gathering routine data lor
administrative purposes
12.8 Reading medical literature
12.9 Seminars with teaching staff
12.10 Individual discussions with
teaching staff
1X11 Time spent in learning
rural life
about
12.12 MCH and family planning clinics
12.13 Specialty clinics
12.14 Didactic Teaching
12.15 School health
12.16 Study block development
organisation
12.17 Environmental sanitation
1X18 Control of communicable diseases
1X19 Vital statistics
For office use only
1
Code
Doctors for the Villages
192
13.
Appendix
How much have you learnt about the following items during internship/housemanship ? Please check
(v/} in appropriate columns below:
Items
Nothing
10)
Poor
fl)
Fair
12)
Good
f3)
193
Used Only Before Internship
erv Good Code
(4)
CONFIDENTIAL
13 1 Clinical ability under rural
conditions
Code No
RURAL HEALTH RESEARCH PROJECT
Instructions
13.2 Understanding epidemiology and
natural history of disease
FORM IY
13.3 Application of piinciplcs of
prevention in clinical practice
13.4 Ability to establish {rood
relationships with villagers
13.5 Understanding ‘oao-economic
factors in disease
13.6 Health Education
13.7
Other community health measures
The following pages contain a number of incomplete
stone. We want you to read and complete them giving
your imaginative best as to what happened from the point
where it was left off.
There are no right or wrong
conclusions to these stories.
13.8 Ability to get along with
professional colleagues and
auxiliaries
13.9 Ability to learn from practical
experience.
Please do not try to read all of them first and then
go back over them to write the conclusions.
13 10 About rural hie-
You have only 5 minutes for each. In order to finish
all of them in the allotted time you will have to write
your • spontaneous reaction immediately after reading
each story.
13.11 Research and survey methodology
13 12 Organization of primary health
centers
For office um only
-
14.
How can the rural internship/housemaastup be improved? Please list your suggestions below.
F0RM,V
N“*
Cod. No...... ................ .
-.............-
-
-
— - Bat.
***■----------------------------- --------.................. — Mcrfkal ColWti_______________________
194
Doctors for the Villages
•' Dr. Singh u a young doctor who has finished a year's surgical house ollicership in his medical college
hospital. He has to choose between two assignments each for a penod of approximately 2 years.
The first is a government primary health center only 5 mrles from the medical college with good road
connections so that it is easy for both patients and the doctor to go back and forth to tha city. The second
is a health center in an isolated valley in the Himalayas, which is supported by his own religious organisation.
It is in an area of great medical need where communications with the outside world are frequently cut off by
weather and bad roads
What choice did he make and why f
Dr Bauerji is a successful practitioner who had never been out of Calcutta. He has just returned
from his first visit to a village where he had gone with a wedding party. In talking with Dr Chatterji, a
young colleague who was born and brought up in a village, he expresses in strong language his revulsion and
disgust al the lack of latenncs in the village. He vows that he will never go back to a village again because
he can't bear the thought of going out to the fields morning and night. Dr. Chatterji responds
195
Appendix
RURAL HEALTH RESEARCH PROJECT
DAILY LOG OF ACTIVITIES
INSTRUCTIONS
Code No.
Day of week
Date__ ______ —.
In the figure on the right, 2-1 hours of the day arc marked starting with
midnight, in half hourly intervals. You are required to indicate the time
spent on different activities listed Mow. Each activity has been given a
number and you are required to indicate the time spent on that
particular activity.
I-or example if you have spent one hour between 7 a.m. and 8 a.m.
in bathing, washing and personal grooming, you will indicate this
activity on the right hand figure as below;
3- Dr. Viswanathan had been surprised to find that his 5 years in a primary health center had passed
as a rapid and pleasant interlude. His wife and two children aged 4} and
enjoyed the life in the village
and the children played happily with some of the village children. One spring day the doctor saw 5 cases of
sever vonnttmg and diarrhoea in the dispensary. On going home he was called next door and found the
4 year old friend of his own child dying of cholera. Dr. Viswanathan immediately
4
'
On graduation from the medical college Dr. Gupta had three alternative choices. He could accept a
job in a government Primary Health Centre where he could start earning Rs 550/- per month. His maternal
uncle who was private practitioner in a big city invited him to join lus clinic as a junior at 200 rupees a
month. He was selected to do post-graduate work in a subject for which he had do particular preference.
After careful consideration Dr. Gupta decided to
Record all activities as starting and/or ending at half hourly intervals.
For example an activity starting between 9.45 a.m. and 10.14 a.m.
is to be recorded as starting at 10 a.m. Similarly activity starting at
10.15 to 10.44 a.m. should be recorded as having started at 10.30 a.m.
Activities and their assigned numbers:
Out patient care —1
In patient care—2
Preventive services for community including health education—3
Preventive Services for Individual patients—4
Studying families—S
Gathering routine data for administrative purposes—6
Reading medical literature—7
Individual discussions with teaching staff—8
Individual Research Projects—9
Seminars with teaching staff—10
Time spent on learning about rural life and contacts with the villagers
not related to specific professional functions—11
Sleeping—12
Eating—13
Bathing, washing and personal grooming—14
Recreation - Indoor activities—IS
Recreation • Outdoor sports—16
General Reading and Writing—17
Any other, specify—II
196
Doctors for the Villages
197
Appendix
Status at the end of rural placement
OODS NO
OONFIDKNTIAL
RURAL HEALTH RESEARCH PROJECT
'SUPERVISOR’S CHECK LIST
Name of Ir.tern/Houseman
Name ol Supervisor'!
filling out form ;J
Dated
Ablllties/Skills
Medic*! College :
.
................
4.
INSTRUCTIONS : Grade according to your best estimate and with maximum objectivity, each intern'o/houioraan's
performance during his/her time with you. We are interested in trying to appraise »mo of the basic attitudes
and skills not usually included in customary evaluations in addition to the more traditionally recognised
professional skills. Check (Vl onc block opposite each Item.
Kindly evaluate on the basis of abilities/skills printed in bold face. Various aspects ol these skills/abilities
are given within brackets for ready reference.
Status at the end of rural placement.
Poor
Fair
Good
Very
Good
No Infor
mation
(1)
(2)
IS)
(«)
<0)
Abilities/Skills
1. Clinical ability
7. Professional relationships
Understanding causation and natural
history epidemiology of disease
(Ability to use epidemiological informa
tion to aid clinical diagnosis : Under
standing the
multiple
causative
factors in any disease rather than
focussing on single etiological agent
and ability to identify the specific
causative factors most amenable to
attack ; Ability to apply epidemiolo
gical methods in solving community
health problems.)
(Willingness to refer problems for expert
consultation;
leadership
qualities;
ability to work with auxiliaries and
subordinates; relationships with other
members of intern group and willingness
to share responsibility.)
8.
3. Application of principles of preven
tion In clinical practice
(Knowledge and use of immunisation ;
Personal hygiene advice to patients ;
Ante-natal and post-natal care to
patients ; Emotional
development
of children ; nutrition ; ability to
foresee and prevent complications.)
5. Understanding of socio-economic
factors in the management of disease
(Awareness of economic implications to
the family of financial loss from disease
nnd ability to gain patient's and families
cooperation in manipulating social »nd
economic factors.)
6. Community Health measures
(Interest and ability in health education;
environmental sanitation, mental health,
MCH and communicable disease control;
ability to see the community as a
whole to recognize the relative impor
tance of its health problems and assign
priorities In solving them.)
(General diagnostic ability ; Knowledge
of appropriate drugs specially those
economically and actually available to
patients ; Readiness to undertake new
therapeutic procedures.)
2.
Code.
Ability to create rapport with
patients and families
(Willingness to listen ; ability to
communicate with patients; ability to
get patients to follow direction about
treatment; sensitivity to emotional
problems and attention to relatives
and families* problems.)
General Interest and enthusiasm
and
9. Regularity
In
punctuality.
attendance
10.
and Intellectual
Personal Integrity
honesty.
11. Attitude to Rural Service.
12. Ability to learn
experience.
1
1
from
practical
13. Humanitarian Motivation for service.
14. For Office Use Only.
Poor
Fair
Good
Very
Good
(1)
(2)
(3)
(<)
fo Infor
mation
(0)
Code.
tne greatest unmet challenge for health
systems in most det eloping countries. The
obvious neglect is not only because the
problems are difficult, but alsc because there
no ready solutions.
Innovative and
realistic field research that takes into account
both the existing situations and the potential
for improvement provides the best hope for
progress. The present study highlights the
feasibility of employing physicians in rural
areas, the conditions under which physicians
might agree to work in villages, and the
structural and organizational changes needed
to improve rural health-care. This study was .
made in India in collaboration with inter-national experts.
lessons learned in this study will have wide :
applicability in all countries.
tji Carl Ernest Taylor is Professor and Chair
It is easy to forget the truism tiiat health- : man of the Department of International
depends upon the quality of health-1 - Health,, the Johns Hopkins University,
personnel as much as on their numbers. But ; School of Hygiene and Public Health,
it is necessary to redefine quality in terms of i ' Baltimore, USA. He is also a member of
what is best for the poor and the deprived jf.y Expert Committees of the World Health
rather than continuing to use the customary ! . Organization, Geneva. Having a teaching,
norms of what is the best care possible for y research and professional experience of
the elite. In most parts of the world, the f S-j several years, Dr Taylor is the author of a
number and distribution of doctors is used i.jq number of investigational and research
as the principal indicator of access to health- ! papers in the field of International Health,
care and its quality. Past research on health- y•' Health Planning in Developing Countries.
care, however, suggests that the organization . Medical Education. Population Dynamics,
of health-care system and the distribution of y Epidemiology of Leprosy, Nutrition and
health-personnel are more significant. It is ..| integration of Health and Family Planning.
increasingly apparent now that the relation- -J§ Joseph DHsmore Alter is Clinical Professor
ship among members of the health-team ;’~ of Community Medicine in the Wright State
requires major changes, which necessitates an : University Medical School, Dayton, Ohio.
analysis of the doctor's role in the health-y.- He was Deputy Director of the Rural Health
care team and his preparation for suchtM
3 Research Project of the Johns Hopkins Uniservice.
versity in India.
The findings of this study will contribute;- ! Prakash L Grover and Sunny Andrews,
to the development of an expanded and
social scientists, were on the staff of the
more ~
Rural Health Research Project of the Johns
Hopkins University in India.
Harbans S Takulia was the chief social
scientist of the Rural Health Research
Project of the Johns Hopkins University,
of which Satya P Sangal was the chief
statistician.
Martha S List has assisted the Report
Preparation Team of the Rural Health
Research Project sponsored by the Depart
ment of International Health, the Johns
Honkins I Fniversifv.
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