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TOWARDS A FAMILY AND COMMUNITY ORIENTED
GENERAL PRACTITIONER :
The elusive goal of Medical Education in India
The Late Dr. Rangarajan Memorial Oration
By
Dr. Ravi Narayan
Community Health Adviser,
Community Health Cell
Society for Community Health Awareness. Research and Action,
Bangalore, - 560 034,
Karnataka
Tel: 080 - 553 15 18 Telefax : 080 - 552 5372
e-mail : sochara@vsnl.com
On
2^ February 2002
at
'Orum 2002
SMF Academy for Continuing Medical Education
Sundaram Medical Foundation
Chennai
TOWARDS A FAMILY AND COMMUNITY ORIENTED
GENERAL PRACTITIONER :
The elusive goal of Medical Education in India
Introduction
In 1972, a young doctor enthused by a three month experience of community practice in
the East Pakistan refugee camps near Calcutta and other short community practice
experiences in urban slums of Bangalore and some rural parts of Karnataka embarked on
a post graduate thesis for his public health degree at the London School of Hygiene and
Tropical Medicine, on the theme "Training Doctors for Community Health Services trends in undergraduate Medical Education in-India”. After a whole year of review, of 25
years of medical literature and dialogue he arrived at seven principles to reorient Medical
Education and make it more relevant to the country’s needs (see Box 1).
Box 1
Training Doctors for Community Health Services
University involvement in health care
Improvement of standards of teaching and teachers
Development of local knowledge and local technology, not just
imports
Appreciation of economy and effective utilization of available
services
> Greater emphasis on general practice and general
practitioners
*** Continuous evaluation of curriculum and innovation
Motivation of medical profession by better role models among
teachers and elders
Source . Narayan, R., DTPH Dissertation, LSHTM. 1973
Significantly, one of the principles was greater emphasis and focus on General
Practice. The dissertation suggested a three-point programme (see Box 2) if this
emphasis was to be translated from rhetoric to reality.
2
Box 2
General Practice in Medical Education
A three point programme
Introducing General Practice Units in hospital outpatients
Involvement of General Practitioners in teaching / training
programmes
*:* Starting General Practice department or speciality in every
medical college.
Source : Narayan, R., DTPH Dissertation, LSHTM, 1973.
Today. 30 years later, after 12 years of being a faculty of a medical college with a
mandate of social / community orientation and 18 years of a health policy researcher
and a health activist with particular focus on medical education and health human
power development, the same doctor stands before you today to reflect on this
elusive goal.
If I was a cynic, I would have probably called this Oration ‘General Practice in
Medical Education : Devalued, Disregarded and Distorted’’ reflecting the reality
of the last 50 years. However, being an unbounded optimist, I have chosen to call it
‘Towards a family and community oriented General Practitioner’ - the elusive goal of
Medical Education in India - to share a vision of a future. I think it is particularly
significant that I give this oration in Forum 2002 that seeks to reach and support the
busy but effective family physician. Even more significant that I do it at the
Sundaram Medical Foundation, an institution nurtured by the late Dr. S. Rangarajan
with a vision and mandate to provide quality medical care to the community that is
effective, affordable, appropriate and regularly audited for quality and relevance.
I thank Dr. Arjun and the faculty of the SMF for this honour and privilege.
1. Goals of Medical Education
Medical Education and its social and community orientation has been a subject for
discussion and dialogue in India especially since the Bhore Committee report of 1946 and
continues to be an area of concern, included in the draft National Health Policy of 2001.
What is the type of doctor we in India have wanted to produce?
The Bhore Committee, 1946
’’The physician of tomorrow.... will be scientist and social worker; ready to cooperate in team
work: in close touch with the people he disinterestedly serves, a friend and leader he directs all his
efforts towards the prevention of disease and becomes a therapist where prevention has broken
down, the social physician, protecting the people and guiding them to a healthier and happier life.
3
The Mudaliar Committee Report, 1961
"Medical education should fit in with the needs of a country
India being more than 80% rural,
the training given to a doctor should enable him to carry on his work among the vast masses in the
villages”.
The Patel Committee, 1970
The Basic Doctor is one who is well conversant with the day to day health problems of the rural
and urban communities and who is able to play an effective role in the curative and preventive
aspects of the regional and national health problems besides being fully well up in clinical
methods
he should have the competence to judge which cases are required to be referred to
a hospital or a specialist. He should be able to give immediate life saving aid in all acute
emergencies. He should be capable of constant advancement in his knowledge by learning things
for himself by having imbibed the proper spint and having learned the proper techniques for this
purpose during his medical course”.
The Srivastava Report, 1975
**The most important is the training of the general medical practitioner who occupies a central
place among the different functionaries needed for the health services. His work is not merely
with treatment of sickness and prevention of disease but also with those social and cultural
problems that contribute to the fabric of health. His commitment is to man and to the human
family. He must change his outlook from an excessive concern with disease to a role of full
social responsibility”
,
The WHO - SEARO ROME report, 1988
"The graduate doctor... responsive to social and societal needs and who possess the appropriate,
ethical, social, technical, scientific and management abilities to enable them to work effectively in
the comprehensive health system based on primary health care ”.
The Bajaj Committee Report, 1989
“A basic doctor, to effectively delivery health care to the country, must be an astute clinician, a
good communicator and educator and a sound administrator, so as to effectively lead an ever
expanding health team for a positive health action work. The action domain of the doctor has
crossed the boundaries of drugs and dispensaries and presently extends to a large extent to the
families and to the communities - hence the need for the basic doctor to be a community
physician..”
The medico friend circle, alternative curriculum, 1991
Community oriented, socially conscious, primary health care provider with competence and
capability
multidisciplinary skills, knowledge and attitudes far beyond conventional medical
boundaries.
MCI Recommendation, 1995
"Graduate medical curriculum is oriented towards training students to undertake the
responsibilities of a physician of first contact who is capable of looking after the preventive,
promotive, curative and rehabilitative aspect of medicine....”.
To summarise these goals, the overall goal of medical education in India is to
produce doctor with the qualities and capacities shown in Box 3
Box 3
Goals of Medical Education
(from Bhore (1946) to draft NHP 2001)
the basic doctor;
community orientation;
*:* family orientation
*:* general medical practitioner
primary health care provider
*:* social physician
astute clinician
good communicator / educator
sound administrator
community physician
2. Initiatives Towards Reaching this Goal
In 1992. my colleagues and I undertook the first serious study to document descriptively
and analytically all the experiments and innovations in the country towards these goals.
The study included an extensive literature review; a survey that identified 30 out of 125
medical colleges that were doing something to reach these goals: a survey of medical
graduates with work experience in peripheral health institutions: and field visits and
interactive dialogue in six key community oriented medical colleges in the country. Of
the 50 innovations, we identified and studied, a few specifically relevant to the goal of
producing community oriented and family oriented general practitioners are outlined.
These were :
Box 4
Initiatives for Reorientation - I
1. Community based orientation camps in first, third and final years
2. Reorienting pharmacology to rational therapeutics, essential
drugs concept and clinical orientation
3. Community based family care programme
4. Special training programmes in
•
Health education
•
Management
•
Health Economics
•
Epidemiology
•
Ethics
•
Nursing
5. Rural / urban slum health visits / camps
6. Curative - preventive General Practice Unit (CPGP)
Source : Strategies for Social Relevance, CHC, 1993-
5
Box 5
Initiatives for Reorientation - II
7
Training in
a. Emergency medicine
b. Social paediatrics
c. Social obstetrics
8. ROME Scheme - mobile hospital scheme
9. Posting to government PHCs and sub-centres
10. Involvement of interns in special field situations
a. Epidemic control
b. Disaster relief
c. Plantations
d. NGO health and development projects
e. Immunization programme
f. Family planning motivation
11 Internship training in specific additional skill
a. Rational drug use
b. Management
c. Ethics
d. Health education
e. Epidemiological projects
f. Clinical research
12. Internship training in GOPD (General Practice Unit)
Source : Strategies for Social Relevance, CHC, 1993.
While taken together they represent quite a significant collection of innovations.
However, the reality was that just a handful of colleges were seriously involved in
these types of innovation. Most others conducted a didactic, unimaginative, orthodox
medical education that was caught up in
the dialectics of the needs of primary health care versus the glamour and demand
of secondary / tertiary health care.
the established middle class culrure of education
<♦ the changing commercial values of students and teachers
❖ the large urban, specialist aspirations in future vocations
<♦ the infectious enthusiasm for hidi tech advances in medicine, the super-specialist
ethos of medical care and the need to keep up with western models and orientation
Not surprisingly the quest for post-graduation / specialisation was high. The quest for
general practice and family medicine low.
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3. General practice related innovation
Surprisingly the only two innovation out of fifty identified had a direct relevance to
general practice was the CPGP unit of Baroda Medical College and the GOPD unit of
MGIMS, Sevagram. What were these initiatives?
a.
The CPGP Unit of Medical College, Baroda
This js an integrated curative and preventive unit with a small lab attached that is
located in the OPD of the teaching hospital and acts as a point of filtration and
referral for patients.
A team of staff pooled from clinical departments and staff of PSM department along
with interns run this unit. All patients who attend hospital OPD arc seen by this unit
and managed as far as possible within the facilities of the unit unless they need
specialist referral. Emphasis on proper documentation and on the preventive and
social aspects of illness and follow up home visits of patients help to give students
and interns an orientation to general practice and family medicine.
h.
GOPD of MGIMS (Mahatma Gandhi Institute of Medical Sciences) Sevagram
The GOPD is a replica of a primary healthy centre but is run as part of a teaching
hospital to inculcate in students and interns the idea and challenges of family medical
practice. The GOPD consists of 7 complementary clinics - a MCH clinic; an
immunization clinic; a TB clinic; a leprosy clinic; a nutrition clinic; a mental health
clinic; a health education cell and a side laboratory. It focusses on teaching students
and interns how to diagnose cases clinically, epidemiologically, socially and how to
advise total management.
While both these units were relevant to giving students a general practice / family
orientation they did not involve local GPs and had became marginalised adjuncts in
the medical college where the rest of the departments continued there ‘east coast of
USA medicine - business as usual’. In Baroda, the innovation wound up with change
of leadership. In Wardha, it has continued but lost some of its original spirit.
c.
Continuing Medical Education for GPs - the CMC-Vellore initiative
The CME programme for General Practitioners started in the late 1980s by CMCVellore is a good example of what can be done by a medical college. The focus has
not only been on updating the knowledge of GPs by self learning modules but the
CME programme has also covered ethics, management and other issues to improve
practice. Much more can be done but this was an excellent beginning.
7
Box 6
‘The General practice unit’
(Posting of students / interns)
1. CROP, Baroda
Integrated curative and preventive unit
OPD of teaching hospital with small lab attached
All patients seen. Referred to specialists only if really necessary
Staff pooled from clinical departments and PSM
Emphasis on preventive and social aspects and good records
Home visits if required
2. GOPD - Sevagram
•
•
•
•
•
‘Replica of PHC in OPD of teaching hospital
Orientation to family medical practice
Seven complementary clinics - MCH, Immunization, TB, Leprosy,
Nutrition, Mental Health, Health Education
Emphasis on clinical, epidemiological and social factors
Training for total management
Source : Strategies for Social Relevance, CHC, 1993
5. Graduate Feedback
50 young graduates who had experience of peripheral health institutions and who were
identified in entrance examinations for post-graduate course in South India, helped us to
get relevant and realistic feedback on what was crucially required if medical education
experience had to prepare young doctors for the challenges of practice, independent
decision making, and the physicians of first contact care.
Practical skill orientation during clinical postings including venesection, lumbar
puncture, minor surgical procedures, etc.
Need to develop reliable clinical skills not too dependent on high tech diagnostics
Need to integrate community, family, preventive and rehabilitative aspects in clinical
training
Need for training in medical ethics; alternate systems of medicine; basic nursing
procedures; communication skills; basics of management / administration; leadership
and training skills; counselling and other non-drug therapies.
While qualitatively this graduate survey - the only one of its type in the country in 50
years was valuable in generating ideas supportive of change i.c., responsive to grassroots
experience, we had cautioned in our report that a more comprehensive feedback should be
facilitated including larger number of general practitioners from small towns and villages
and medical officer of primary health centres. Such a survey has not yet taken place.
&
6. What has gone wrong?
We see therefore that while the goals of medical education in India has been stated to be
towards the basic doctor - a community and family oriented general practitioners: and
there has been some efforts towards this by a few colleges through innovations and
initiatives in the training programme, including two initiatives focussed on general
practice and family medicine itself, by and large the overall trends have been surprisingly
consistent and in the opposite direction.
The Srivastava report of 1974 sums it up aptly....
Box 7
Situation Analysis of the 1970s
•
“The strangle hold of the inherited system of medical
education
•
The exclusive orientation towards the teaching hospital
•
The increasing trend towards specialisation and
acquisition of post-graduate degrees
•
The lack of incentives and adequate recognition for work
within communities (including general practice)
•
The attraction of the export market for medical
manpower
These are factors responsible for the aloofness of medicine
from the basic health needs of the people”
Source : Srivastava Report. 1974
Is the situation any different in 2002 A.D.?
While all these factors are still relevant today, I would like to suggest another list of
factors that look at this problem from a different angle particularly in the context of the
growing paradox in the country.
It needs urgently general practitioners and family physicians and is getting mostly
doctors preoccupied with high tech secondary and tertiary care increasingly
commercialised, bio-medicalised, and irrelevant to the social-economic-politicalcultural realities of the large majority of our people.
Medicine as a social service and a vocarion is fast developing into medical business with
a profit motive. What has gone wrong? Unlike the Srivastava report which was a polite
professional assessment, I believe the dme has come to be incisive. The 'professional
conspiracy of silence’ has to give way ;o accepting evidence as reality.
We cannot be part of a solution if we do not first realise we are still part of the problem.
9
What are these factors?
a.
The devaluation of General Practice in Medical Colleges
In most medical colleges, with the over emphasis of the teaching hospital as a base for
clinical training, there is a subtle devaluation of general practice in the minds of the
young doctors. Clinicians often go out of their way to exaggerate the incompetence
of a GP or family physician when a referral case is seen with complications or
otherwise. Rather than endorsing the fact that for every complicated referral there are
hundreds of routine cases that are being managed by the busy GP, the young medico
is made aware of the incompetence or ineffectivity of the GP’s role.
b.
The cultural colonialism of Medicine
Even though nearly six decades have passed since we achieved independence, the
colonial mentality of the medical profession, the elite bureaucracy and the political
leadership have not disappeared. What is 'west is best'! Still rules the medical mind.
The craze for foreign degrees, foreign linkages and 'east cost of USA medicine'
foreign technology and foreign medical culture has increased. The brown sahebs who
rule India have deep roots in their background and education which make them see
dictates of western society as more important than basic needs and aspirations of our
people. Neem, turmeric, yoga, meditation find respectability only when they are
endorsed by the west. When will this end?
c.
The commercialisation of medical practice
Over the years, medical practice has been increasingly commercialised. The
commercialisation has included the mushrooming of private health care institutions;
the growth of high technology diagnostic centres; the concurrent glorification of high
technology through high pressure advertising in the media; the problem of private
practice among full time teachers of medical colleges; the 'increasing doctor-drug
producer axis' and the growing vested interested in the 'abundance of ill health'; the
increasing spread of kick backs, cm practice and now even cut throat practice!
d.
The 'cancer' of Capitation Fees Medical College
Commercialisation beyond privatisation
One of the 'concerns’ of medical education is the mushrooming of capitation fee
colleges based on caste, communal and political affiliations. No amount of name
changing to 'self financing', private etc., will make any change in their questionable
respectability. There is growing evidence how they have used their lobby to corrupt
the exam systems, promote the fall in standards; and use their money power and
political influence to affect admissions, appointments, results. The nexus between
capitation fees lobby and the political system are well established.
10
e.
The inadequacy ofpresent day Continuing Medical Education
Most continuing education for practitioners is mostly content education or, technical
information transfer focussing on content, seldom on process or context. There are
numerous CME selling products and technologies. Hardly any on improving the
standards of medical practice or improving cost -consciousness, effectivity and
efficiency in general practice; or promoting quality assurance, or enhancing, ethical,
social, epidemiological, management or communication capacities.
The pseudosocialism of our political and professional leadership
The political leadership and the leaders of the medical profession have found it in the
interest of the elite and privileged sections of the community to promote the social
goals of medical education as political and populist rhetonc. However, in actual
practice they have neglected primary health care and promoted secondary and tertiary
care in urban areas with highly sophisticated technology that has served their own
class. All this through heavy subsidy by the government in the name of the people.
Now with the neo-liberal economics even this populist rhetoric is being jettisoned;
with more and more of the leadership seeking medical care in centres of excellence
abroad. In the new draft NHP 2001 even this pretence is dropped and the policy
makers want to convert India into the Mecca of modem medicine promoting medical
tourism and further commercialisation.
The distorted expectations of the citizens
By the constant education of the profession, media and leadership, the citizens of the
country are also opting for more and more medicine; demanding injection, tonic and
high tech diagnostics; and completely ignoring our own long standing folk health
traditions that have stood the test of time. Rice kanji is giving yvay to electral; non
drug traditions ofyoga and meditation are giving way to costly adjuncts to therapy.
h.
The complex pathology ofpresent day medical college leadership
Our national study identified 12 pathologies of present day leadership. I am sure to
many of you this would be very familiar.
| Confusion between excellence / relevance
Mental Disorientation
Continuous shift between tertiary and primary’ care
I Nystagmus
Reduced field of vision / orientation
I Optic Atrophy
weak individualistic selective responses
Anemia
Effect of market value and promoting commercialisation
Cancer
Depressive Too much planning too little follow up
Manic
Psychosis
Allergy of students to badly planned programmes
Atopy
Rounmzanon affecting creativity
Arteriosclerosis
Clinical community dialectics
I Schizophrenia
Unsuccessful transplants of foreign ideas
Graft rejection
Staff withdrawal due to cynicism
i Autism
i Status quo. lack of openness to change
; Senile dementia
In this multidimensional pathology, little change or reorientation can be nurtured.
n
i.
Corruption in Medical Education and Society
Corruption has become the bane of public and private life in India and has crept into
all sectors of development and human endeavour. Medical education is no exception.
Influence of money power and power politics in the selection of candidates for
admissions; selection of teachers for appointments; modifying examination results;
extraneous influences on promotions, transfers, research and training grants and the
concerns growth of private practice ethos in patient care within government hospitals
and health care services are all manifestations of this problem. Recently, as a policy
researchers, I helped the Karnataka Government Task Force in Health and FamilyWelfare explore this new public health challenge. Two examples of reality quoted in
the Task Force Report should shock us out of our professional smugness:
<♦ Junior doctors testified that the large majority pay charges to examiners at
designated centres to prevent being failed!
In a corporation maternity centre, the charge to see a newborn baby is Rs. 500/if male and less iffemale!
Where is medical education and health care headings
/•
Too much diagnosis : too little treatment
The rhetoric for reform and reorientation has gone on too long. Much of the literature
on medical education has been filled with what is wrong - case of over diagnosis and
under treatment. Small efforts and innovations are ignored or poorly documented.
Innovations are hardly subjected to evidence based evaluations, peer review or any
objective analysis. There is need to change this. Teachers and students must demand
change. Patients and citizens must exert social pressure. Health is both a right and a
responsibility.
7. The Way Ahead - Challenges and Oprions
What can we all do to reverse these trends and to bring back medical education on track
and focus it specially towards general practice and family medicine?
a. Bring 'Ethics' back into the Health Profession
This is an urgent imperative if the people are not to lose faith and respect for what, till
has recently been considered a noble social vocation. Prof. Madhav Menon of the
National Law School University- of India has suggested that this ‘Back to Ethics’
movement must have five principles
<♦ Profession for the people (not prints)
<♦ Respect for patient autonomy and human rights
<♦ Duty to protect life and reduce suffering
(no financial exploitation, emoncnal exploitation, sexual exploitation, etc.)
Duty to act fairly
(Hallmark of civilised society nd objective of all the law-s and regulations that
govern us)
<♦ Professional accountability.
*2
Two significant initiatives in this direction have been
i.
The Rajiv Gandhi University of Health Sciences in Karnataka is the first
university in the country to introduce Medical Ethics as a separate curriculum
subject in all the Medical Colleges under its jurisdiction.
Box 10
Ethics Course
’’Doctors and other health professionals are confronted with
many ethics issues and problems with advances in science and
technology.
These problems are on the increase.
It is
necessary for every doctor to be aware of these problems. The
doctor should be trained to analyse the ethical problems as they
arise and deal with them in an acceptable manner. It is therefore
recommended that teaching of Medical Ethics be introduced in
Phase I and continued throughout the course including the
internship period".
RGUHS ordinance, 1997-98
11.
Some ethical doctors in Mumbai have set up the Forum for Medical Ethics and
bring out a regular bulletin called Issues in Medical Ethics that is for the first time
raising a host of issues for debate and critical reflection within the profession.
(sandhva@medicalethicsindia.org; subscribe@medicalethicsindia.org
b. Bring 'General Practice1 and 4Family Medicine1 to the core of Medical Education,
Medical Care and Health Services
The focus must change from specialists and secondary / tertiary care centres in urban
areas back to the 'central’ role and need for good 'general practitioners’ and 'Family
Physician' - a group that has been ignored, disregarded, neglected for too long.
It is time that GPs / Family Physicians are seen as major contributors to Health Care,
as the face and heart of the profession.
I personally believe that to be a good ethical GP or family physician, socially relevant
and community and family oriented today is far more specialised task - with its own
multidisciplinary capacity and challenge. The cardio-thoracic surgeon and the
neurosurgeon pale into insignificance as ‘glorified technicians’ in comparison.
13
Box 11
The low skill - high skill shift
(GPs and Family Physicians)
The community oriented. Primary Health Care doctor is by no means a
‘basic’, second rate, or low-skill doctor as is made out by the
protagonists of the conventional curriculum. She/He needs greater
competence and capability to work in the community and has to develop
multidisciplinary skills, knowledge and attitudes far beyond conventional
medical boundaries. Her/His specialist colleague, while certainly being
necessary for delivering highly technical medical services has the
disadvantage that she/he can function only at secondary and tertiary
levels with an array of infrastructural and technological and senior peer
group support. But in the present system, she/he is at best a glorified
technician. This shift of emphasis is basic to the development of the
community oriented doctor.
Source : mfc anthology 1991
Four (4) concrete steps can be taken to do this
GPs and Family Physicians should be made role models for young doctors
by inviting them to teach, share experiences and challenges during the medical
course.
a.
GPs and Family Physicians should be given linkages to Medical Colleges as
teachers / visiting faculty.
m.
GPs and Family Physicians should be linked to government hospitals,
private hospitals as frontline extensions for home/family/community care and
follow up.
iv.
Medical Colleges, professional associations must organise Continuing
Medical Education that go far beyond information transfer on the latest in
medicine to building up skills and capacities required for improving the
standards, quality, scope and framework of general practice, family practice in
the community.
These will include at leastfour to being with
<♦ Ethics
<♦ Management
Communication and
<♦ A Item a five systems
The first to humanise the profession; the second to make it more efficient and
cost and quality conscious; the third to help it build patient autonomy and
rights; the fourth to locate it in the rich plural traditions of the country and help
to give the patient and his family the best options for care.
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c.
To generate competence in evidence based Rational Medicine and Health Care
It is not just a question of ‘ethics’ and respectability. What is needed urgently is also
good science and if one looks around what has changed in recent years is not just the
ethics of the medical profession, but a lot of what we do is ‘unscientific’ and
‘irrational’.
These fall into three major technical categories
I.
Irrational Diagnosis
ii.
Irrational Treatment practices
iii.
‘Ritual Mutilations’ or unnecessary surgeries
Each of these is a subject by itself but we need to look at them seriously, undertake
action research studies; peer review; evidence-based reviews^ and evolve counter
strategies. Some examples:
<♦ Why is the rate of caesarean sections going up?
(40% of lower middle class women in a SMF survey!)
Why are ‘injections; and ‘tonics’ and ‘saline’ becoming the sheet anchor of
general practice?
Why are CT scans and MRIs becoming big business suddenly?
Why are we continuing to dispose medical wastes irrationally?
Why are antibiotics being misused, over used, abused in the country?
The list of questions for which evidence is required is endless!
What can we all do about it? Can we have better recording / reporting mechanisms to
enhance the data for such decision making. Can more MD Thesis and dissertations
look at these issues? Can centres such as SMF do more action research studies with a
network of GPs and family physicians to gather evidence on these trends'?
H e all need to network and tackle this problem and generate a new movement for
Evidence based Medicine and Health Care?
d. Promote ‘civic society' participation in Medical and Health policy - The Peoples
Health Movement factor
For too long the Medical Profession and the Medical Education sector have been
directed by professional control and debate. It is time to recognise the role of the
community, the consumer, the patient, and the people in the whole debate. Bringing
Medical Service under the preview of the Consumer Protection Act has been the first
of the required changes. Promoting public debate, review and scrutiny into the
planning dialogue for reform or reorientation has to be the next step. This could be
brought about by the involvement of peoples / consumers representatives at all levels
of the system - be it service, training or research sectors. However all these steps can
never be brought about by a top down process. What is needed is a strong
countervailing movement initiated by health and development activist, consumer and
people’s organisations that will bring health care and medical education and their
right orientation high on the political agenda of the country.
15
The whole mobilization that 18 National Networks did last year for the Jana Swasthya
Sabha (the first National Peoples Health Assembly) in Kolkata, December 2000 and
the global Peoples Health Assembly was in this direction.
Significantly, one of the 5 booklet that emerged as a consensus document was entitled
‘Confronting the Commercialisation of Health Care’- which brought a peoples
perspectives on Rational Medical Care. Private health sector in India. Medical Ethics.
Medical Education and Health Care in India. Now translated into all the Indian
languages it has started the peoples dialogue on these issues which is long overdue.
The final page of this booklet is significant to this reflection.
PHA and Health Care
The focus of the Peoples Health Assembly is on
Recommendations to Government and professional bodies on
measures - legal and administrative needed to check this
commercialisation and keep medical practice effective, safe,
cheap and holistic.
On peoples initiatives and mass mobilization to educate the
people on their rights, help them with strategies to cope
individually and as communities with the problems due to
commercialisation of health care and to build up public
awareness for reform of the medical sector.
All those concerned about Peoples Health needs and Peoples
Health will have to take on this emerging challenge as we begin
the new millennium. Our efforts will determine whether in the
years to come, health care and medical education will primarily
respond to the peoples health needs and aspirations or will
professional expectations and market phenomena continue to
distort the process.
MARKET or PEOPLE? What will be our choice?
Source : PHA Booklet - 5
e. Recognising and Promoting the Paradigm Shift
Finally, the greatest challenge to all of us health care providers - at whatever level we
may be and particularly for general practitioners, family physicians, PHC doctors,
community health doctors and to health policy makers and opinion leaders of the
health professions at all levels is the urgent need to recognise the ’paradigm shift’
required if ’Health for All’ has to become a reality any time in the future.
We have been promoting this new paradigm for over 15 years since we see this as the
only way we can move ahead.
First we must move our focus from individuals to family and community in all that
we do.
Secondly, we must move beyond the biomedical and physical dimension to explore
the psychosocial, economic, cultural, political and ecological dimensions of every'
health problem we tackle (including stigma, poverty, social burden).
Thirdly, we must move away from our preoccupation with drugs and vaccines to
education and social processes and non-drug therapies including life style change as
the focus of our efforts.
Fourthly, our health care providing should move away from dependency creation and
mystification and professional control to greater enabling, empowering and autonomy
building among our patients and the people we serve.
Fifthly, our attitude to patients should move away from considering them as passive
beneficiaries to active participant of all our services and our programmes.
Finally, our research efforts must move beyond orthodox molecular biology and
pharmaco therapeutics to socio-epidemiology and behavioural sciences.
In this new health revolution - the new movement towards a more relevant paradigm
of health and health care, general practitioners and family physicians will become
the centre of the process - the core of the health care services since they are best
suited, most capable and best located in the health care - community continuum to
herald this new thinking, this new value, this new paradigm.
Specialists experts, those who are compartmentalised by their training of knowing
more and more about less and less will then have to move to the margins of this new
health care revolution.
A time has come to make this paradigm shift from specialist care to family practice.
ARE WE READY FOR THIS CHALLENGE?
Acknowledgement
To all my Community Health Cell (CHC) and medico friend circle (mfc) colleagues who
throughout the years have kept up my optimism, interest and commitment to these ideas
through interactive dialogue and peer support.
To two special role models on the theme of the oration. Dr. Shirdi Prasad Tekur, a CHC
colleague who has
been an ideal family physician involved in plural medicine and
Dr. Prakash Rao, a CHC associate, a busy GP who in spite of all the demands of practice
has kept his commitment to rational practice and involvement in broader social issues as
the coordinator of Drug Action Forum-Kamataka - they give me confidence in what I
have said.
To all the fellow activists of the Jana Swasthya Abhiyan who have through their
enthusiasm proved that these ideas are no longer rhetorical.
Finally to Sundaram Medical Foundation for this opportunity, to V.N. Nagaraja Rao of
CHC for the excellent secretarial support and to all at CHC for keeping up the efforts. •
References
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Trends in undergraduate Medical Education in India : Training Doctors for Community
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Central Bureau of Health Intelligence, Directorate General of Health Services, Ministry of
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Health for All - an Alternative Strategy, ICSSR/ICMR Study Group report, Indian Institute
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National Education Policy in Health Sciences
IJME. Vol. 29, Nos. 1 & 2, p 35-55 (Jan-Aug 1991)
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Recommendations of Workshop on Need-based curriculum for Undergraduate Medical
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Medical Education Re-examined (Ed. Dhruv Mankad), Medico Friend Circle / Centre for
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Strategies for greater community orientation and social relevance in Medical Education
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Curriculum Change : Building on graduate doctor feedback of peripheral health care
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Reorientation of Medical Education - Goals, Strategies and Targets
WHO-SEARO Regional Office, Publication No. 18, Booklet No. 2, New Delhi.
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Perspectives in Medical Education, Health Policy Series, VHAI, 2001
11. NCC, Jana Swasthya Sabha (2000)
Confronting the commercialisation of Health Care
Jana Swasthya Sabha Booklet, No. 5. South Vision, Chennai, July 2000.
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