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CPHE
PERSPECTIVES IN MEDICAL EDUCATION
A REPORT PREPARED FOR
THE INDEPENDENT COMMISSION ON HEALTH IN INDIA
DECEMBER 1995
SOCIETY FOR COMMUNITY HEALTH AWARENESS
RESEARCH AND ACTION
BANGALORE - 560 034
INDIA
REORIENTATION OF MEDICAL EDUCATION
"The implementation effort must be bold; halfhearted attempts
to make changes without really changing will be expensive
and destructive. Not only is there no point in waiting,
because the eventual change of health care system is certain,
bue delay will contribute to very avoidable misery and death.
A timid approach will harden opposition, waste resources and
discredit the strategy. We are about to take a quantum leap into
an eminently attainable new era in human development:
we should be careful to lose neither our will nor our way.
WHO-SEARO (1988)
PERSPECTIVES IN MEDICAL EDUCATION
CONTENT LIST
FOREWORD
1.
PREAMBLE
1
2.
DIAGNOSIS OF THE PROBLEM
5
SITUATION ANALYSIS
REGIONAL DISTRIBUTION AND DISPARITY
COMMERCIALIZATION - BEYOND PRIVATIZATION
PROBLEMS OF NORMS AND ESTIMATES
STUDENT WASTAGE AND BRAIN DRAIN
QUALITATIVE DECLINE IN STANDARDS
ADMISSION REQUIREMENTS AND SELECTION
PROCEDURES
2.8 TEACHING FACULTY
2.9 CURRICULUM DEVELOPMENT / RECOMMENDATION
2.10 COST / FINANCING OF MEDICAL EDUCATION
2.11 CORRUPTION IN MEDICAL EDUCATION
2.12 MEDICAL STUDENTS - PROTEST MOVEMENTS
2.13 POSTGRADUATE COURSES
2.14 CONTINUING EDUCATION
2.15 MEDICAL COUNCIL OF INDIA
2 16 EXPERT COMMITTEES AND POLICY REVIEWS
2.1.
2.2.
2.3
2.4
2.5
2.6
2.7
3.
APPROACHES TO TREATMENT
5
5
13
14
15
20
21
27
29
31
32
33
34
36
37
38
43
3.1
3.2
3.3
3.4
THE KOTTAYAM EXPERIMENT
THE ROME EXPERIMENT
DEVELOPMENT OF THE HEALTH UNIVERSITY CONCEPT
MEDICAL COLLEGE INITIATIVES
3 4a IMPROVING PEDAGOGY OF MEDICAL EDUCATION
3.4 b MOVING BEYOND THE TEACHING HOSPITAL
3.4 c WIDENING HORIZONS
3.4 d IMPROVING SKILL DEVELOPMENT
3.4 e TRANSCENDING COMPARTMENTALIZATION
3.4 f PROMOTING SELF LEARNING
43
45
46
47
47
49
53
54
55
56
3.5
3.6
3.7
GRADUATE FEED BACK
THE COMMUNITY HEALTH TRAINERS OF THE VOLUNTARY SECTOR
ALTERNATIVE TRACKS AND EXPERIMENTAL PARALLEL SECTOR
3.7a THE JNU PLEA FOR A NEW PUBLIC HEALTH CURRICULUM
3.7b THE mfc ANTHOLOGY OF IDEAS
3.7c THE ALTERNATIVE TRACK
3.7d THE MIRAJ MANIFESTO
3.7e THE MCl'S ALTERNATIVE TRACK
3 7f THE CONSORTIUM OF MEDICAL COLLEGES
58
60
62
63
64
66
66
67
67
3.8
FRAMEWORK OF THE ALTERNATIVE
68
il
4
EMERGING TRENDS
THE SOCIAL CONTEXT OF CHANGE
THE HEALTH SCENARIO IN INDIA
4.1
4.2
PRESCRIPTION FOR CHANGE
5
69
69
71
75
5.1
ISSUES IN MEDICAL EDUCATION
S.laTHE POVERTY - SICKNESS CONTINUUM
5 1 b COUNTERING THE VESTED INTEREST IN ILL HEALTH
5.1c EDUCATIONAL TRANSFORMATION
5.1 d FROM EXHORTATION TO ROLE MODELS
5.1e COLLECTIVE LEADERSHIP
5 If THE COLLEGE WITHOUT WALLS
5 1g TOWARDS A CREATIVE AUTONOMY
75
75
75
75
76
76
77
77
5.2
THE KEY TO CHANGE
5.2.1 BAN ON MEDICAL COLLEGE EXPANSION
5.2.2 STRENGTHENING OF MCI
5.2.3. NATIONAL HEALTH COMMISSION
52.4. MEDICAL EDUCATION REFORM TO BE STRENGTHENED
5.2.5. EXAMINATION REFORM
5.2.6. ESTABLISHING A FRAMEWORK FOR CREATIVE AUTONOMY
5'2.7. CONTINUING EDUCATION
5.2.8. POSTGRADUATE EDUCATION
5 2 9. RESEARCH IN HEALTH HUMAN RESOURCE
DEVELOPMENT TO BE PROMOTED
5.2.10 REGULATION OF PRIVATE SECTOR / PRIVATIZATION IN HEALTH
CARE / MEDICAL EDUCATION TRENDS
5.2.11 BEYOND DOCTORS - TO HEALTH TEAMS OF PHCs
5.2.12 THE PEOPLES HEALTH MOVEMENT FACTOR
78
78
78
79
79
81
81
82
82
83
83
84
84
6.
REFERENCES
85
7.
ACKNOWLEDGEMENTS
86
li
STATISTICAL TABLES AND OTHER DATA
1.
Growth of Medical Colleges and Admissions since Independence
6
2.
Regional Distribution and status against entitlement
7
3.
Pattern of Growth of Medical Colleges by Regions (1965 /1995)
8
4.
Regional pattern of growth in Medical Colleges in Decades
9
5.
Male and Female Admission Trends
10
6.
Distribution of Medical Colleges by Size (All India)
11
Distribution of Medical Colleges by Size (Pattern in State)
12
8.
Methods of Selection
22
9.
Reservation in Medical Seats and Regional Pattern
23-25
i) Main categories
ii) Special categories
iii) Other categories
10.
Doctors Registered with State Medical Council
16
11.
Doctor Population Ratios - with and without Alternative System practitioners
17
12.
Number of colleges and admission of Alternative Systems of Medicine
18
13.
Speciality wise seats available in Postgraduate Medical course
in India - Broad Groupings
35
14.
List of Medical Colleges included in the tables
87-88
[NOTE: It has been very difficult to get comprehensive, authentic and current information on all
aspects of Medical Colleges in the country from Governmental / Official sources. Surprisingly data
is contradictory and incomplete. We have used a Private Published guide (1994), used by
students seeking Medical College admissions in the country. This has been supplemented or
integrated with data available from Government and Professional Publications. It has not been
possible in the time available to cross check the data against official statistics. The overall trends,
however have been interpreted with necessary caution).
FOREWORD
This report, prepared for the Independent Commission on Health in India, by the
Society for Community Health Awareness, Research and Action, brings
together, over a decade of involvement, in evolving alternative perspectives on
Medical Education and Health Human power Development. Our efforts have
been geared to making these more relevant to the health needs of our people
'--'j—--' relevant to our times.
More specifically, the report draws extensively on the findings of an interactive
research project, initiated in 1990, to study the Indian experience in evolving
strategies for Social Relevance and Community Orientation in Medical
Education.
The research initiative focussed on a wide variety of experience, collating data
and ideas through a multipronged, data collection, methodology. This included:
Experts'. A study of recommendations from Shore Committee report
(1946) till the Draft National Educational Policy for Health Sciences
(1989).
* Institutional initiatives: A survey of medical college initiatives and
a field study of seven pace-setter colleges.
* Experience in the Field: A Survey of feedback from young medical
graduates with work experience in peripheral rural hospitals and health
projects.
* Training Alternatives: A study of alternative training experiments
in the Voluntary Health Sector.
* Dialogue with innovaters: A series of dialogues with the key
initiators of experiments within the 'medical college system' and the
voluntary sector
* Social context: In addition, the society also undertook a
comprehensive Policy Delphi Survey on the Social, Economic and
Political trends in the country having an impact on Health and the
health issues and challenges emerging in this context. The scenario
forecast by this exercise has been kept in context while evolving this
report and its recommendations.
(i)
This report draws extensively on these research initiatives, supplemented by
data and reports collected on the situation, after the Society was requested to
report on the theme, to the Commission.
In keeping with the Independent Health Commission's terms of reference
i) to 'identify the maladies affecting the present health care system' and
ii) to 'provide pragmatic and people oriented solutions'.
the report has attempted to provide background for both these objectives.
In the foreword to the Society's Project report, February 1993, Prof. V.
Ramalingaswami, Chairman, Task Force on Health Research for Development,
WHO - Geneva, had observed that "the principles of educational reform may be
applicable globally but the solutions have a location specificity. The intrinsic
elements of the change process are the teachers, students and the institutional
framework; the extrinsic elements are political will, administrative commitment
and social pressure".
All these elements have been reviewed and dealt with in this document.
The subject of Medical Education and its social and community orientation has
been a subject for discussion, dialogue and policy concern since Independence
and perhaps even more concertedly since the Srivastava Report of 1974. Much
has been written, but the problems and obstacles to change remain and the
crisis of the widening, gap between needs and expectations versus the actual
ground realities is becoming more acute day by day.
The report therefore tries to focus on key issues of concern and key components
of immediate action. It attempts to be brief and provide a practical rationale for
change.
THE TIME FOR RADICAL AND CONCERTED ACTION IS NOW!
Community Health Cell,
Society for Community Health Awareness,
Research and Action,
No. 326, Fifth Main,
First Block, Koramangala,
Bangalore - 560 034.
Karnataka.
December, 1995
(ii)
/
PERSPECTIVES IN MEDICAL EDUCATION
1. PREAMBLE
1 The Goals of Medical Education, in the country, have been clearly de fined
and endorsed throughout the last five decades since Independence.
* The 'Social Physician' of the Shore Committee Report (1946) and the Mudaliar
report (1961);
* the 'Basic Doctor' of the Patel report (1970);
* the 'Family and Community Oriented general practitioners with social
responsibility' of the Srivastava Report' (1975)
* the 'community oriented physician for comprehensive health care of the ICSSR
IICMR Health for all Report (1981); and
* the 'Community Physician' of the recently drafted National Educational Policy
for Health Sciences (1990);
have all underlined the acute need of a new type of doctor, that we need in this
country.
I
I
2) The 'Institutional Framework' for achieving this goal have seen a massive
quantitative expansion since 1947,
* From 25 colleges producing 959 doctors in 1947-48 to around 145 colleges
producing over 14,000 doctors in 1993-94, recording a 600% expansion in
nearly five decades.
* The quantitative expansion, is equally significant in a global context, with India
having 10 percent of the medical colleges in the whole world (over 140 out of
1400 colleges).
3) The 'Curriculum Reorientation' recommended by Medical Council of India, (the
apex National body set up to evolve norms and guidelines for medical education
in the country), has also seen a continuous process of change.
* The introduction of the subject of Preventive and Social Medicine (now
extending in its framework from preclinical years to the final year);
* the evolution and organisation of rural and urban field practice areas that
provide opportunity for training beyond the teaching hospital;
1
* the evolution and organisation of the Compulsory rotating internship after the
final examination, which includes 3/6 months of community based postings;
are three important and significant reforms, among many others, endorsed and
recommended to medical colleges, towards the goal of producing 'basic doctors'.
4. The populist rhetoric of Doctors for Rural Areas has become an integral part of
policy formulation; political party manifesto; social exhortation at every level; and
media and professional reflection and debate - not showing any decrease in
intensity over 40 years.
5 POLICY GAP
However inspite of
a) clarity in the stated goals of policy;
b) phenomenal quantitative growth in the institutional framework;
c) some efforts to qualitatively reorient the curriculum to match the policy goals;
and
d) the enhanced populist rhetoric;
the situation of medical education in the country has moved towards greater and
greater crisis.
i. The majority of the young doctors still opt for urban hospital and urban clinic
practice and the trends towards specialization are high.
ii. The vacancies in rural and peripheral community based health centres and
hospitals in the government services have reached significant proportions.
VACANCIES IN HEALTH CENTRE
"The State of Maharashtra which accounts for almost one fifth of
the total national out turn of doctors annually, has about onefourth of the sanctioned post of doctors at PHC's lying vacant as
of 1st January of the current year. Uttar Pradesh with seven
medical colleges has forty percent of similar posts lying vacant
II
Bajaj, 1994 (13
iii. Professional preoccupation, both at 'practitioner' and 'educator' levels
continue to be with illness care at secondary and tertiary level centres, rather
than with the challenges of care at the primary health / community levels.
iv. Finally since the late 1970's there has been an emergence of a large number
of
2
/
disturbing trends in medical education and health service development in the
country which are beginning to have an definitive eroding affect on the focus and
orientation of health service development and the nature and goals of medical
education in the country. These include among others:
- the growth of 'capitation fee' colleges;
- the mushrooming of institutions based on 'caste' and communal affiliations;
- the increasing commercialization of health care;
- the mushrooming of private high tech diagnostic centres and the inevitable
glorification of high tech tertiary care at the cost of primary health care
priorities;
- the increased 'doctor-drug producer axis' with 'vested interest' in the
'abundance
of ill health' and the enhanced growth of a powerful medical industrial complex.
- the increasing erosion of norms of medical ethics and increase in medical
malpractice;
- the unresolved and increasing problem of private practice among full time
medical college teachers.
This crisis between stated goals and policy formulations versus actual realities, is
the theme of this report. This report is being presented in four sections.
DIAGNOSIS OF THE PROBLEM
A brief situation analysis of all aspects of Medical Education in India identifying
salient features; matters of concern and recommendations and prescriptions of
expert committees and others; and identifying critical issues that have not been
given adequate consideration.
3
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i
i
PERSPECTIVES IN MEDICAL EDUCATION
2. DIAGNOSIS OF THE PROBLEM
An overview of the growth and development of Medical Education in the country,
since Independence is a necessary pre-requisite to understand th?
of
change and the complexities of the emerging problems.
2 1. SITUATION ANALYSIS
The country has witnessed a tremendous growth in the infrastructure and
facilities for Medical Education since Independence. A perusal of tables 1 and 5
will highlight the following salient features:
a) There has been a massive, quantitative expansion in Medical college facilities
in the country - from 22 colleges in 1947 admitting 1983 students to 145
colleges admitting approximately 16,200 students annually in 1993. This
represents a 600% expansion in colleges and 800% expansion in admissions.
b) The Male-female ratios in admission and output have increased gradually from
78:22 in 1971 to 60:40 in 1990, with an unusual peak of over 41% admissions of
female in 1977-78 and a corresponding peak of female doctors graduates in
1982-83 (44%). The overall trend has been positive and more female doctors
needed by the country are being catered for.
c) The increase was gradual till 1975. Then following the Srivastava Report
there was a plateau till 1985 and then another phase of expansion, till the
Presidential ordinance in 1993.
The phase till 1974 was predominantly an increase in government sponsored
colleges, and the phase after 1988 was predominantly the commercialization and
private sector phase of medical college expansion.
d) Till 1985, we were fairly consistent about the number of colleges in the country
- without much variance between government and non-government sources.
Since 1985, even the publically stated estimates have varied from 130 to 170.
The most recent estimate of the new Health Minister is 200(1).
2.2. REGIONAL DISTRIBUTION AND DISPARITY: (The BIMAROU dilemma!)
Based on the Mudaliar Committee norm of one college per 50 lakh (5 million)
population, a review of the present regional distribution of colleges in the country
taken against the 1991 census estimates show important trends (see tables 2, 4
and 6).
a) Some states like Karnataka, Maharashtra, Tamilnadu and Union Territory of
Delhi show a number far beyond their entitlement and requirement.
5
TABLE 1
GROWTH OF MEDICAL COLLEGES AND ADMISSIONS SINCE INDEPENDENCE ( 1947-93}
________________ __________________
YEAR
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1993
# N.A.
SOURCES :
NO. OF
MEDICAL
COLLEGES
ADMISSIONS
22
30
30
30
31
31
31
31
31
52
52
52
52
52
79
79
79
79
79
87
95
98
100
105
105
106
106
106
106
106
106
106
106
106
106
122
125
128
128
128
145
1 ,983
2,811
2,609
2,675
2,489
2,691
2,846
3,087
3,660
3,958
4,083
4,554
4,904
5,874
6,846
7,719
9,697
9,897
10,520
10,620
12,029
12,048
11,772
13,205
11,561
11,281
11,176
11,117
10,658
11,021
11,101
10,749
11,054
10,877
10,610
10,090
11,622
14,166
13,262
11,791
16,200
NOT AVAILABLE
1, 4, 9
6
OUTPUT
959
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
10825
11311
11364
11911
11982
11962
13783
12190
13429
12170
12197
15992
10511
10469
11470
12280
12100
12292
N.A.
N.A.
/
TABLE 2
REBItm DISTRIBUTION AND STATUS ABAINST ENTITLEMENT - 1993
SL.
NO.
STATES
1
MOEA PRADESH
2
3
4
5
6
7
ASSAM
BIHAR *
GUJARAT
HIMCHAL PRADESH
JWfU It KASK1IR
POPULATION
1991 CENSUS
(MILLIONS)
ACTUAL
COLLEGES
ENTITLE
MENT * *
ND. OF
SEATS
COMMENTS /
OBSERVATIONS
1993
10
13
4
17
8
3
66.50
22.40
86.40
41.30
16.50
5.20
7.70
3
9
6
2
1
1
2
9
3
19
1120
365
580
885
150
65
260
3266
ADEQUATE
ADEQUATE
SHORTFALL
700
ADEQUATE
SHORTFALL
ADEQUATE
ADEQUATE
ADEQUATE
ADEQUATE
MSSIVE EXPANSION
CAPITATION / COMTEK
-CIALIZATION TREND
8
KARNATAKA
45.00
9
10
KERALA
MADHYA PRADESH
MAHARASHTRA* 6 GOA
29.10
66.20
80.10
6
13
16
5
6
30
ORISSA
31.70
PUNJAB
20.30
44.00
56.70
6
4
9
3
6
6
15
520
610
1590
TREND INITIATED
SHORTFALL
11
12
13
14
15
RAJASTHAN
TAMILNADU * It POWICHER/
11
720
3004
MASSIVE EXPANSION
CAPITATION / C0HER
-CIALIZATION TREND
321
SHORTFALL
ADEQUATE
ADEQUATE
MODERATE EXPANSION
COMMERCIALIZATION
16
UTTAR PRADESH
139.10
28
9
1071
17
18
19
WEST BENGAL
DELHI
NORTH EAST EXCLUDING
ASSAM
68.10
7
4
755
SHORTFALL
9.40
14
2
460
EXCESS
9.10
2
1
85
ADEQUATE
1.60
0
0
0
846.40
168
145
16527
20
OTHER STATES /
UNION TERRITORIES
TOTAL
iissssszssi
BX<-XZSSS8fi5SSSSSSZSSXSXXXSSSS3 S3ZS3333«33«Z33S83SS^8S8:
L
SOURCES : 6, 10, 11
♦ IFFOWWTION ON ONE COLLEGE IN BESE THREE STATES ARE NOT AVAILABLE.
** NORM: 1 MDICAL COLLEGE / 5 MlllON PEOPLE
7
TABLE 3
PATTERN OF GROWTH - NO. OF MEDICAL COLLEGES BY REGIONS
AND STATES - 1965 AND 1995
ZONE / STATE
NO. OF MEDICAL
COLLEGES
IAMR - 1965
NO. OF MEDICAL
COLLEGES - DIRECTORY
OF MEDICAL COLLEGES
IN INDIA - 1995
7
6
6
9
3
4
3
9
3
5
3
7
e
9
4
10
19
5
9
15
5
6
30
CENTRAL ZONE
MADHYA PRADESH
UTTAR PRADESH
EASTERN ZONE
ASSAM
BIHAR
MANIPUR
ORISSA
WEST BENGAL
1
SOUTHERN ZONE
I
i
ANDHRA PRADESH
KARNATAKA
KERALA
TAMILNADU
PONDICHERRY
|
I
WESTERN ZONE
*
GUJARAT
MAHARASHTRA & GOA
11
NOTHERN ZONE
JAMMU
KASHMIR
HARYANA
HIMACHAL PRADESH
PUNJAB
RAJASTHAN
DELHI
1
3
2
5
5
3
6
6
4
1
145
88
= =st = = = = = =: = = = = = = = = = = = t
K S = S=
SOURCES ;
* I AMR
1,
6,
9
- INSTITUTE OF APPLIED MANPOWER RESEARCH
8
I
TABLE 4
REGIONAL pattern of growth of medical colleges in decades
STATES / UNION
TERRITORIES
PRE 1950 1950-59 1960-69 1970-79 1980-89 1990-94
3
ASSAM
1
2
BIHAR
2
3
GUJARAT
2
4
1
2
1
GOA
1
HARYANA
1
HIMACHAL PRADESH
1
1
JAMMU & KASHMIR
KARNATAKA
2
1
4
ANDHRA PRADESH
1
KERALA
3
5
2
2
MADHYA PRADESH
2
2
2
MAHARASHTRA
4
1
4
1
1
1
8
1
2
10
8
1
MANIPUR
ORISSA
1
1
1
PUNJAB
1
2
1
1
1
1
3
1
1
1
5
RAJASTHAN
TAMIL NADU
3
UTTAR PRADESH
2
WEST BENGAL
4
1
DELHI
1
2
1
1
5
1
2
1
1
PONDICHERRY
TOTAL
CUMULATIVE TOTAL
4
27
27
41
91
23
50
13
104
27
131
12
143 *
ESEXSESSEEEEEEES E^S = E E E = E E S fe E E E E B E E BESESESS Z S = X S S E zsa = ss:ascs:ciEcs = sisx
* YEAR ESTABLISHED
NOT GIVEN FOR 2 COLLEGES
Source 6,10
9
TABLE 5
MALE AND FEMALE ADMISSION TRENDS
MALE*
FEMALE*
1971-72
98
78
21.5
1972-73
100
77.6
1973-74
105
1974-75
YEAR
(
QUALIFIED
ADMISSIONS
NO. OF
MEDICAL
COLLEGES
TOTAL
TOTAL
MALE*
FEMALE*
12048
73
26.9
10825
22
11772
74.6
25
11311
79
20.7
13205
76.5
23
11364
105
78
21.8
11561
76
23.8
11911
1975-76
106
77.9
22
11213
77
22.5
11982
1976-77
106
75.5
24
11176
77
22.5
11962
1977-78
106
58
41.8
11117
78
21.8
13783
1978-79
106
72.6
27
10658
79
20.7
12190
1979-80
107
70
29.7
11021
79
20.8
13429
1980-81
109
69
30.8
11101
77
22.7
12170
1981-82
111
67.8
32
10749
74.5
25
12197
1982-83
111
63
36.8
10784
55.9
... ;44|
15992
1983-84
Ill
N.R.
N.R.
10877
71.6
28
10511
1984-85
116
63.6
36
10610
70.7
29
10469
1985-86
122
62.6
37.3
10090
67.3
32.6
11470
1986-87
125
61.5
38
11622
65.6
34
12280
1987-88
128
61
38.9
14166
63.7
36
12100
1988-89
128
60
39.8
13262
62.9
37
12292
1989-90
128
60
39.8
11791
N.R.
N.R.
* N.R.
NOT RECEIVED
SOURCES : 4 , 9
10
N.R.
TABLE 6
DISTRIBUTION OF MEDICAL COLLEGES BY SEATS
SIZE OF COLLEGES (BY SEATS) - 1993
r
NO. OF
COLLEGES
TOTAL
35
1
50
60
64
65
70
75
18
5
35
900
300
80
1
1
NO. OF
SEATE
CUMULATIVE
-rr-.-y '
t-
85
90
100
102
107
110
113
115
118
120
125
130
140
150
155
170
175
180
185
195
191
200
210
240
300
328
I
64
130
140
150
80
85
180
4100
102
321
440
113
115
118
720
375
780
560
1650
155
170
875
540
370
390
191
1OOO
210
240
600
328
1
2
2
2
2
41
1
3
4
1
1
1
6
3
6
4
11
1
1
5
3
2
2
1
5
1
1
2
1
= 3E = s=xs:xsss=c:=:s:a
c = = :ss:s:=:=s:=::=s=se = =: = s:
TOTAL 142
*
THREE COLLEGES - SEAT TOTALS NOT AVAILABLE
SOURCE
s
10
11
933
1235
129c;
1429
1569
1719
1799
1884
2064
6164
6266
6587
7027
7140
7255
7373
8093
8468
9248
9808
11458
11613
11783
12658
13198
13568
13958
14149
15149
15359
£ r '- r -
16199
16527
I
TABLE 7
DISTRIBUTION OF COLLEGES BY SEATS ( REGIONAL PATTERN)
?
STATES / UNION
TERRITORIES
ANDHRA PRADESH
ASSAM
BIHAR (-1) *
GUJARAT
GOA
HARYANA
HIMACHAL PRADESH
JAMMU k KASHMIR
KARNATAKA
KERALA
MADHYA PRADESH
MAHARASHTRA (-1) »
MANIPUR
ORISSA
PUNJAB
RAJASTHM
TAMIL NADU (-1) *
UTTAR PRADESH
WEST BENGAL
DELHI
PONDICHERRY
T
50
60
80
no
100
90
140
130
120
150
1 '(125) - 2
6
(65) - 1
160
170
2
I
2
2
180
1
I
4
1
1
1
(35) 1
:it5) -1
(65) - 1
1
1
4
I
1
1 (64) - 1
I
2
1
3
1
16
118) - 1
3
2
I
i
2
4
(85) - 1 I
Ii
(107) - 3
3
1
1
1
3
1
1
(75) - 1
i!
1
2I
1
1 !
3
1
2
3
125) - 2
2 (102) - 1 113) - 1
I
(50) - 18
19
I
5 (70) - 2 (80) - 1 (90) - 2
J65) - 2 (75) - 2 (85) - 1
(65) - 1
5
5
3
li
3 (155) - 1
1
1
(75) - 1 ■
j(35) - 1
TOTAL (-3)
70
3
41 (110) - 4 120) - 6(130) - 6
(107) - 3 115) - 1 125) - 2
(102) - 1 118) - 1
113) - 1
41
8
9
9
* INFORMATION OF TOTAL SEATS OF THREE COLLEGES IN EACH OF THESE STATES ARE NOT AVAILABLE
^2
4
11 (155) - 1 ,
I
I
4
11
I I
200
190
250
300
TOTAL
1120
365
580
(175) - 2
(210) - 1
885
70
150
65
260
(175) - 1 185) - li
1 ;
328) - 1 3266
2 Ii
700
720
2 (240) - I
2934
85
321
520
610
(175) - 3
1515
185) - 1 191) - 1
1071
755
1
460
75
1 1180) - 3 195) - 2 200) - M210) - 1 300) - 2 16527
(175) - 5 185) - 2 191) - 1(240) - 1 328) - 1
1
8
4
6
2
3
/
Especially in the first two states mentioned, this trend is further underlined by the
association with the privatization / commercialization trend as well.
b) Some states like Bihar, Madhya Pradesh, Uttar Pradesh, have colleges far
below their entitlement (nearly 50% less). Orissa, Gujarat, Rajasthan and West
Bengal also have comparitively less than their entitlement.
c) At a National level, the overall situation evens out with only a small shortfall.
However the same regional planning distortions, seen in all aspects of Health
Care planning in the country are seen.
d) The Regional disparity are characterized by another feature. Karnataka and
Maharashtra, the commercial belt, also have the largest admission ratios thereby
proving the economy of scale theory - more admission more income and profits!
2.3, COMMERCIALIZATION - BEYOND PRIVATIZATION
In terms of ownership and governance there has been a gradual increase in the
number of colleges run under the auspices of the Private Sector (Trusts or
Societies) from less than 5% at the time of Independence to 30% in 1993-94
(see table 2).
While 'private sector1 support to higher education may not be a negative trend
per se, it is significant that most of the more recent entrants into the private
sector group of medical colleges show the following characteristics:
- They belong to the 'capitation fee' charging variety of medical colleges and the
magnitude of this fees has been increasing over the years; (from 1 lakh to 30-35
lakhs per seat I)
- They are initiated by trusts and societies often with caste / communal
affiliations;
- They are initiated by individuals representing specific sectoral interests like
sugar barons in Maharashtra State, or liquor barons and other pressure groups in
Karnataka and Andhra Pradesh, all of whom are not conversant with the
objectives of medical education;
It is quite significant that all the unrecognised medical colleges in the country (26
out of 146 estimated by the Ministry of Health and Family Welfare, Annual
Report 1993-94) are in this group.
These represent a trend of Commercialization of Medical Education which is
significantly different from the issue of privatization of higher education.
Further, reports in the media are regularly available of how colleges run on the
capitation fees ethos are also contributing to fall in qualitative standards at the
time of examinations, where money, power and political influence affect results.
13
The 'nexus' between the capitation fees colleges lobby and the political system
through contribution to party funding is also a subject of media report and
debate.
2.4. PROBLEMS OF NORMS AND ESTIMATES : SHORTFALL OR EXCESS?
The growth of medical colleges in the country has resulted from a application of
the Mudaliar Committee norm of 1 Doctor per 3000-3500 population and the
norm of 1 medical college per 5 million population. With a growing population,
these norms have kept up the momentum of expansion.
However, we would like to emphasise that in our considered opinion the situation
in the country with its present stock of 300,000+ doctors is one of having Too
many doctors, not less. Some important facts that underscore this opinion are:
a) The Shore and Mudaliar Committees used only 'MBBS Graduates' as being
doctors in all their calculations and estimates.
In the Indian situation we have trained practitioners of a range of alternative
systems. At the primary care level all these can be considered to be contributing
to the health care delivery system.
When their numbers - estimated from Government reports are included in
deriving doctor - population ratios then the situation changes remarkably to an
excess rather than the deficiency situation, usually portrayed (see table 11).
b) It is now well documented that majority of the doctors who graduate from the
145 medical colleges (presently established in India) are not motivated to public
health / primary health care and opt for specialization and/or urban practice.
The doctor-population estimates are further skewed by this factor - so we have
an increasing number of the wrong type of doctors in the wrong situation. Rural,
tribal and hilly areas are underserved while urban areas have an excess.
Doctor population ratios also show wide regional disparities.
c) Finally the estimates of 'brain-drain' both external (from India to the developed
world) and internal (from the public sector to the profit oriented private urban
sector) is variable but on the whole have been showing an increasing trend. It
has been now well established that the tax-payer supported governmental
medical education sector benefits the private sector in the country and the health
service sector of the established market economies of the western world, more
than the health services of the government.
14
/
While factor (a) explodes the myth of the shortage, (b) and (c) underscore that
any increase in the existing type of MBBS doctors is unlikely to make any impact
on the problem.
It is not at all surprising that as early as 1980, the ICSSR / ICMR Health for all
Study Groups categorically stated that “Two immediate decisions will have to
be taken.
i) There should be no new medical colleges and no increase in the intake of
existing medical colleges.
ii) There is no need at all to set up new and additional institutions to train
additional doctors through short term courses".
2.5) STUDENT WASTAGE ANP BRAIN PRAIN
Successful human power development policies presuppose that efforts or
resources paid for by the tax payer in training should bear returns of fully
qualified personnel, reaching the required positions, to confidently and efficiently
provide service to the community.
Wastage occurs if students discontinue or delay their studies or trained
personnel seek avenues of work other than support to the public services eg:
through brain drain to developed or other countries and so on.
Studies on ‘Wastage1 and 'Brain drain' have been rather inadequately pursued in
the country. These are particularly important because there is both a urgent
need for trained manpower, especially in situations of disadvantage as well as a
shortage of resources, to facilitate their training.
The Institute of Applied Manpower Research in collaboration with National
Institute of Health Administration and Education conducted the only known study
on wastage. However, the data was from 7 colleges only, out of the potential 36
in the sample and the period of study 1954-56. Real wastage (not completing
the course) was 6% and time wastage (delays in completing the course) was 912%. Compared to studies done in India and elsewhere these were not very
alarming. However, these were not followed up.
Another area which has not received adequate attention is the attrition rate
among women doctors due to family demands and child bearing. This is
particularly important since there has been an attempt to increase the number of
females at the intake stage, which is welcome (see table 5) .
However large attrition during the course or after graduation would make this
shift counterproductive. This area of study should also help identify ways and
means of support to female doctors to prevent attrition due to family demands
and facilitation of reentry into the profession, with continuing education and other
supports at a later stage as well.
In terms of 'Brain Drain', studies have been done to estimate the magnitude of
15
TABLE 10
DOCTORS REGISTERED WITH STATE MEDICAL COUNCILS (1984-1990)
1984
1985
1986
1987
1988
1989
1990
ANDHIA PRADESH
15373
15990
16516
17108
17639
18236
18898
ASSM
8279
8640
8912
9145
9428
9746
10099
GUJARAT
16955
17669
18417
19173
19806
20701
21576
21621
22217
22902
23450
24137
24872
25689
JAfflU I KASWIR
3103
3289
3442
3622
3676
3937
4087
KARNATMA
23470
24490
25518
26722
39355
40672
42399
BHOPAL (M.PJ
6473
7141
7867
8526
9147
9852 • 10542
MAHARASHTRA
35585
37394
39397
41035
42730
44684 | 46858
ORISSA
8831
9378
9478
9866
10081
10426
PUNJAB
23096
23632
24128
24615
25130
25598 [ 26178
RAJASTWW
10065
10501
11059
11613
12243
12912
13475
TAMILNADU
35644
36860
38673
40023
41465
43074
44769
IUTTAR PRADESH
26613
27584
28514
29376
30348
31336 ' 32369
WEST BENGAL
35986
37005
37751
38738
39510
40210 . 40920 j
iTRAWWCORE (KERALA)
13644
14208
14900
15568
16455 N.A. *
12153 1 12469
MME OF STATE
JOICAL COUNCIL
10746
H.A.
12805 i 13199!
(HYDERABAD (A.P.)
!
11091
11504
11780
HARYMA
1
N.A.
N.A.
256
319 I
437
523 | N.A.
N.A.
N.A.
794
830
1639
2412
3196
295829
307502
320304
331882
355695
352196
365000
i
MCI
TOTAL
SSSKSZ23^CS83S=S3ZSSSSZSSsisSSZBS3:
« N.A.
SOURCE i 5, 10
= NOT AVAILABLE
16
TABLE 11
DOCTOR POPULATION RATIOS - ALLOPATHIC SYSTEM AND INCLUDING PRACTITIONERS
OF ALTERNATIVE SYSTEM OF MEDICINE
POPULA- DOCTOR POPULATION
TION
(MILLIONS)
6i7
(7)
ALLO
PATHS
HOMEO
PATHS
AYUR
VEDA
SIDHA
UNANI
TOTAL
(1)
(2)
(3)
(4)
<5)
<6)
1974
190838
145434
223109
10128
30400
607909
590 1:3091
1:970
1979
249752
112638
225477
18093
25988
631948
660 1:2642
1:1044
1981
268712
115710
233824
18357
28737
665340
683 1:2541
1:1026
1984
297228
123852
251071
11352
28382
711885
735
1:2472
1:1032
1985
306966
123852
251071
11352
28382
721623
750 1:2443
1:1039
1986
319254
131091
272800
11581
28711
763437
767 1:2402
1:1004
1987
331886
N.A.
N.A.
N.A.
N.A.
N.A.
783 1:2359
N.A.
1988
355695
N.A.
N.A.
N.A.
N.A.
N.A.
800 1:2249
N.A.
1989
352196
N.A.
N.A.
N.A.
N.A.
N.A.
817 1:2319
N.A.
1990
365000
N.A.
N.A.
N.A.
N.A.
N.A.
834 1:2284
N.A.
1991
394060
N.A.
N.A.
N.A.
N.A.
N.A.
851
1:2159
N.A.
YEARS
SS flE Efi SE 8S SE S 3E S 93BMtflB3Bnnan3S9B
SOURCE : 7,
17
10
TABLE 12
HD. OF COLLEGES Ah© ADMISSIONS OF ALTERNATIVE SYSTEMS OF MEDICINES (1991)
Wfi)HRA PRADESH
3
no
ASSM
1
25
BW
11 (3)* 190
GUJARAT
9
258
HARYANA
4
200
HOEOPATHY
NO. OF : ADMISSION
COLLEGES' CAPACITY
UNANI
ND. OF J ADMISSION
AYURVEDA / SIDDHA
ADMISSION
NO. OF :
CAPACITY
COLLEGES'.
STATES / UNION
TERRITORIES
colleges:
2
1
capacity
80
40
TOTAL
ND. OF
COLLESES
TOTAL
NO. OF
ADMISSION
3
125
8
315
5
200
6
225
26 2135 (16)
38
2355
190
12
448
3
200
4
i
I
HIMACHAL PRADESH
1
50
1
50
JMMU I KASHMIR
1
0
1
0
KARMTAKA
8
195
645
KERALA
5
170
MADHYA PRADESH
7
187
MAimSHTRA
17
795
ORISSA
2
PUNJAB
1
15
6
435
15
4
250
9
I
420
1
25
13
490
21
702
1
50
24
1221
42
2066
60
3
140
5
200
3
130
3
140
6
270
3
180
3
80(2)
3
140
9
400
2*1 «
115
1
15
1
21
5
151
UTTAL PRADESH
9
410
4
180
16
670
29
1260
NEST BENGAL
4 120 (2)
10
1236
14
1356
DELHI
4
150
2
50
1
60
7
260
94+1
3335
16
535
120
7453
232
11323
RAJASTHAN
TAMIL NADU
TOTAL
i
I
I
I
:SZZSZ3SZBZZZZZ3Z3ZZZZCzfezZ33338Z3ZZ33ZZXZ88Z33ZZ83 EZSZS3XS3Z*S»SSSte3S3S£B3S3S33
ZZ8SS3S3SZZ8S8SX383Z888SSZ3S8Z83SZZZ38Z8Z88888ZS:
SOURCE « 2
4
FIGURES IN 0 BRACKETS INDICATE REPORTING UNITS
44 SIDDHA - 1
18
migration and to enumerate 'push' and 'puli' faptors. But here again no serious
attempts have been made to identify the economic losses due to the drain. In
more recent years, with the focus on NRI investments in the development
process, the drain of doctors to lucrative practice overseas is often seen as a
'gain' rather than a 'drain', further complicating the issue.
A study of Doctors migrating has shown a steady increase from an annual
average of 810 during the I plan phase to 5304 in 1986-87 (which represents
nearlv 30% of annual output) which is remarkably high.
This is therefore an area of importance for continuous monitoring and study,
because of the broader economic - political - social - cultural context of this
phenomena. For instance, the recent phenomena of NRIs from the US
promoting High technology Diagnostic Centres in the country can be seen as the
MNCs in USA opening new market avenues for high tech gadget, whose sale in
the US has shown a slump in recent years. Thus while the NRI process in
Health care is often portrayed in the media and policy formulations as an
'altrustic process' in reality it is a 'market economy process'. In addition there is a
cultural aspect as well - that of the promotion of Western Health Care as being of
higher standard than Indian health care, not withstanding the serious cultural and
economic crisis being faced by the Western Health Care itself I
Much of the so called Continuing Education efforts that has become common in
more recent years, especially linked to NRI supported hospitals and diagnostic
centres is primarily focussed on stimulating the local medical profession to catch
up with the technological gadgetry of the west. The support of the growing
Medical - Industrial complex to this Continuing Education efforts is therefore not
at all surprising.
!
"The training of health services personnel
should be fully oriented to the people their social, cultural and economic
conditions and their health profile"
- ICSSR-ICMR Health for All Report, 1981
19
2.6) QUALITATIVE DECLINE IN STANDARDS
Medical Council of India has from time to time laid down a) guidelines for
minimum standards for medical colleges; b) guidelines for the framework and
content of medical curriculum; and c) guidelines for the minimum qualifications
and experiences of teachers for medical colleges.
These norms and guidelines for standard 100 seat medical colleges are
upgraded from time to time. They are applied at the time of comprehensive
inspection and recognition of new colleges and through the concurrent
monitoring system of a schedule, sent in by the colleges once every 5 years to
maintain the registration system. Repeat inspections are also carried out.
Senior faculty in the Medical profession are used as certified MCI inspectors to
visit institutions and maintain standards.
While in principle, the MCI guidelines were meant to maintain standards during
the post-independence phase of expansion, in practice they were not able to
establish a consistent and high standard of education in the country leading to,
what is now 'universally accepted' as a major decline in standards.
Key factors contributing to this decline inspite of the presence of a National Body
like MCI are:
i) The sector of Education in the Constitutional Schedule is part of the concurrent
list. While Central Government and national bodies can recommend norms and
standards, it is State Governments and State Universities that are finally
responsible for the actual developments. As seen in the 'mushrooming of
capitation fees colleges' issue, state governments and universities have
accorded recognition to local colleges inspite of MCI norms even on the
capitation fees issues.
ii) MCI inspectors have not been able to maintain the high standards of
enforcement required by them. As in all aspects of life in the country, corruption
and the extraneous influences of money power or political interference have
managed to circumvent the inspection mechanism.
iii) In the context of the Norms available at present, MCI inspectors tend to
concentrate primarily on infrastructure and staff position rather than quality /
methodology / orientation of medical education. Hence even in colleges which
have been certified as being recognition worthy on the basis of infrastructure and
faculty norms, the quality of medical education has been declining.
The decline in standards, that have been seen in more recent years, have been
quite remarkable and it would not be 'rash' to state that if an objective evaluation
were to be made of the 135 odd medical colleges presently recognised by the
MCI, using its own minimum requirements norms, then atleast 50% of the
colleges would have to be derecognised immediately.
20
/
2,7, ADMISSION REQUIREMENTS AND SELECTION PROCEDURES
An overview of available information on 145 recognised / unrecognised medical
colleges in India (1994) shows that the Admission requirements and selection
procedures show an overall uniformity with some regional variation. These are
as iOiiows:
ADMISSION REQUIREMENTS
An age restriction of 17 years is universal. In addition PUC as qualifying
examination with certain minimum levels of marks in the Science subjects have
been laid down by MCI and generally accepted. Domicle restrictions vary from
state to state, though most cater to students primarily from their own states.
Reservations are available for varying socially disadvantaged categories but the
extent of reservation varies. These include SC, ST, OBC, children of defence
personnel, Government of India nominees, religious groups, especially in
institutions run by religious minorities, rural candidates. Less commonly reservations are available in a few institutions for disabled, special areas like
border areas, tribal areas and a host of other subgroups (see table 9A - 9C of
supplement).
1
MCI has recommended Medical exam for fitness in 1971. In 1977 it included
NCC, sports and athletics, and minimum 10% reservation for candidates from
other states in the context of National integration efforts. These have been
accepted by some institutions only.
SELECTION PROCEDURES
The PUC qualifying exam marks are an important factor for selection in 30% of
the colleges. Many colleges now accept the Central and State Government run
centralised examinations for medical / dental seats (50%).
A few colleges have their own entrance examinations and a selection interview.
Only two have other methods at the time of selection including aptitude / value
testing group dynamics and leadership skills and other skills assessed by
various observation tests (SJMC - Bangalore, CMC, Vellore). Table 8 provides
an overview of the different selection procedures and the percentages of
colleges that include them in the selection process at present.
21
<
TABLE 8
METHOD OF SELECTION
METHOD OF SELECTION IN MEDICAL COLLEGES
1) QUALIFYING EXAM (PUC / BSc.)
NO. OF
MEDICAL
COLLEGES
PERCEN- TAGE
35
8
24.14
5.52
TOTAL
PERCEN- TAGE
1
i
a) Me rit in the Qualifying Exam and
Interview
b) Marks obtained in the Science Subject-s
I
i
29.66
43
*TOTAL
!
2) COMMON ENTRANCE TEST
I
a)
b)
c)
d)
Written
Objective Type
Both
Medical and Dental Admission test
and objective type
e) Common Pre—Medical test and
Interview
I
i
20
20
10
13.79
13.79
6.90
8
5.52
11.03
16
I
Own entrance test, AND Interview, Group
Observation, Psychological test as
well as values test
4) CAPITATION FEES *
5) NOT AVAILABLE
51.03
74
TOTAL
3) MULTI STAGE SELECTION PATTERN
•f
I
!
2
1.38
23
15.86
3
2.07
_____ L
100
145
GRAND TOTAL
==±
=:=:=: = = = = =: = =:=: = = e = s = =: = = = = = = = = =: = = = := =
SOURCE : 6,
* FOR MANAGEMENT QUOTAS
22
10
/
TABLE 9A
RESERVATION IN MEDICAL SEATS - A
STATES / UNION
TERRITORIES
ANDWA PRADESH
15
6
25
ASSAM
7
15
6 SEATS
BIHAR
14
10
23
6UJMAT
7
13
GOA
15
HIMACML PRADESH
13.8
JWHJ It KASHMIR
8
I
45X (164 SEATS)
S0£ X
15X (ALL INDIA)
10
IX (10 SEATS)
15X (ALL INDIA)
4
SOME X
15X (ALL INDIA)
54X (GENERAL)
30 (ALL INDIA)
3
3 SEATS
i
TRIPURA-3 SEATS
7.6
3
15 (ALL INDIA)
43 (CENTRAL)
21
SOME X
SOME X
SOME X
2
8
KERALA
5% (20 SEATS)
736
SOME X
KMWTAKA
GENERAL
IX (12 SEATS)
30
22
BOTH 33.6
GOVT. OF
INDIA
NOMINEE
WOMENX
BOX
ST*
SC %
SOME X
SOME X
25
4
15
MADHYA PRADESH
BOTH 15
IUHMASHTRA
BOTH 10 SEATS
SOME X
40
15 (ALL INDIA)
65 (KERALA STATE M
15 (ALL INDIA)
SOME X
35X
fwupur
12
8
ORISSA
2
BOTH 25
PUNJAB
RAJASTHAN
SOME X
15 (ALL INDIA)
STATE GOVT.
NOMINEE - SOMEX
28
15 (ALL IM)IA)
15 (ALL IWIA)
8
6
18
1
50
SOKE X
10
2
15
SOfE X
50 (30 WOMEN)
SOME X
15 (ALL INDIA)
X (STATE GOVT.)
15 (ALL INDIA)
t
TAMIL NADU
UTTAR PRADESH
I
SOME X
SOME X
DELHI
15
7.5
PONDICHERRY
7
5
NEST BENGAL
12 (OTHER
STATES) *
24
31X
38X
14X (ALL INDIA)
88S8SSXX8SS883X888;sLsscssss=sx=8x»==sxsssa=szs«x«=fcszessss«8x»8ZS==3stsss=s==s»ase«««s«4xcs8x««xsc3a5=sx=«x'a8==xssssc=B==se«sxc5
sL
* FROM ARUMCHAL PRADESH, AWAMAN It NICOBAR ISLANDS, DADAR & NAGAR HAVEL I
LADAK, KMPUR, MEGMLAYA, MIZORAM, NAGALAND, SIKKIM AND TRIPURA
23
TABLE 9B
RESERVATION IN MEDICAL SEATS
9B
TOTAL
STATES
SPECIAL CATEGORIES
ANDHRA PRADESH, GUJARAT, GOA,
HARYANA, HIMACHAL PRADESH, KARNATAKA
MADHYA PRADESH, ORISSA, PUNJAB
RAJASTHAN
10
ASSAM, GOA, HARYANA, HIMACHAL PRADESH
JAMMU
KASHMIR, MADHYA PRADESH,
UTTAR PRADESH AND DELHI
8
HARYANA, GOA, KERALA, PUNJAB,
UTTAR PRADESH, AND DELHI
6
KARNATAKA, GOA, ANDHRA PRADESH
MAHARASHTRA, ORISSA, RAJASTHAN,
UTTAR PRADESH
7
! 5)
KARNATAKA, JAMMU
ANDHRA PRADESH
3
i 6) CENTRAL / STATE
GOA, ASSAM, JAMMU
MAHARASHTRA
1 ) CHILDREN OF SERVICE/
EXSERVICE MEN
I
2)
'
-
r
i
i
CHILDREN OF FREEDOM
FIGHTERS
CHILDREN OF DECEASED/
DISABLED DEFENCE
OFFICERS
i 4) PHYSICALLY HANDICAPPED
i
I
I
. NCC, SPORTS PERSONS
GOVERNMENT DEFENCE
EMPLOYEES
KASHMIR,
KASHMIR,
ss5 = = = = =:xs:s:=:s=3=c-s = — = = csxz!fcx: = = = = s: = c:=:s:=:s:c = =: = = = eE: = = * = = K«*= = *a = = =:® = s= — =
SOURCE :
10
C RELEVANT
o
o
o
Pmvxio
3
2
I
o
> |
o
MJ
Z
2
3
24
4
L
I
-
_m=.
-
RESERVATION IN MEDICAL SEATS - 9C
STATES
OTHER CATEGORIES
Assam, Manipur,
Delhi
1 ) Other States - Meghalaya, Mizoram, Tripura
Nagaland, Arunachal Pradesh
I
2) Tea Garden Labour, Immigrant Muslims.
I Children of Employees of Central Govt.
Assani
I
3) Self financing Nepalese students, TISCCj
Sri Lakshmi Narayan Trust, Coal Mines
Welfare Organisation
I
i 4) Donors Nominee, Armed Forces Personnel
!5)
Gujjar, Backward, other Social Castes
District LCH, District Kargil, Areas near
actual line of control, children of
permanent resident Defence Personnel
Bihar
Gu. jarat
Jammu & Kashmir
6) Children of Political Sufferers
Karnataka
7) Horanadu, Gadinadu Kannadigas, Anglo
Indians, Parsi Community, Diploma Holders
Karnataka
Punjab
*8) Nominees, OPH Candidates, Degree / Diploma
holders in Ayurveda and Homeopathy, Kerala
origin settled in Andaman
Nicobar Islands
and Lakshadweep, Nominees of Drugs control
Dept, and D.Pharma holders. Departmental
Kerala
Candidates (B.Sc.)
9) NRIs, Maharashtra - Karnataka disputed
area border residents, Nominees of Miraj
Medical Centre and Nominees of donors at
R.A. Podar Medical (Ayurvedic College)
Bombay
. Maharashtra
10)[Green Card Holders
! Orissa
llteorder area. Wards of gallantry awardees,
Children / Widows of Punjab Police, PAP,
Punjab Home Guard Personnel (killed /
disabled), November 1984 riot affected
displaced persons, terrorists affected,
wards of Medical staff of Guru Gobind
I
Singh Medical College
Pun j ab
;;= = = _ = = = ste. = = = = = s= = = = = = = = = = = = = = = = = » = = = » = = = a = = = = - = = = = = = =E = = * = = x: = = = WCI = =
□URCE : 10
25
CAPITATION FEES AS A SELECTION PROCEDURE
Among the more recently opened colleges, donations and capitation fees is a
major factor of selection representing the commercialization of the medical
education sector (16%). The capitation fees range from 10 to 35 lakhs and NRI's
pay upto 100,000 US $ (media reports).
Inspite of official stands, mostly 'lip service' against capitation fees by the
government - (both at central and state level) and professional councils and
bodies at all levels, the capitation fees lobby group of medical colleges has been
gaining greater and greater patronage by the active connivance of both
professional and political leadership.
In state like Karnataka - even the cabinet meet to decide on the permissible
levels of capitation fees which are then applied and not surprisingly, exceeded by
irregular and unofficial means.
The Supreme Court Judgement in a special writ petition from Andhra has
established that capitation fees as it is practiced today "violates the right to
education under the constitution;
is wholly arbitrary;
is unconstitu
is evil, unreasonable, unfair and unfit
and enables the rich to take admissions whereas the poor have to withdraw due
to financial inability
;
and therefore is not permissible in any form
"
In spite of this, the crisis continues and the growth of such colleges continues
unchecked.
The nexus between the capitation fees lobby
and the Medical Education policy makers and
leadership at state / central levels is therefore
an important area that needs urgent study if the
commercialization of medical education has
to be halted.
26
2.8) TEACHING FACULTY
The development and training of faculty for Medical Colleges has been a greatly
neglected area inspite of all the rhetoric about 'standards' and inspite of
guidelines drawn up for their numbers, qualifications and selections.
a) Vacancies
While data on current availability and the actual shortfalls are not easily available
at state or central level, there is increasing concern that this is becoming a major
problem. In states like Karanataka, with the unchecked proliferation of private
capitation fees colleges the depletion or shift of faculty from Government
colleges to private colleges in the lure of better pecuniary benefits has become a
serious problem. In the near future, this could lead to a situation of potential
derecognition, of the government colleges themselves.
b) Private Practice
While MCI and state / central government and most professional bodies have
endorsed in the past the need for teachers of medical colleges to be full-time
non-practicing, this situation is changing rapidly with clandestine or officially
sanctioned private practice, becoming common place.
The logic of the rule was to ensure that medical teachers were available for
improving and sustaining the quality of care in teaching hospitals; available for
formal and informal training of junior doctors, interns and students; and involved
in research to maintain standards and keep abreast of growing professional
knowledge.
The situation is rather different now, by both default and design, affecting quality
of care in teaching hospitals and quality of teaching and research as well. In
addition it has contributed to the entry of 'market economy' values and ethics into
teaching hospitals compromising professional standards and technical
excellence. This has further compounded the corruption and decline in
standards that have been noticed in government hospitals over the years.
Under pressure of the Medical profession, who are getting more and more
involved with lucrative and competitive practice, more colleges are beginning to
reconsider this rule and allow various forms of practice, to the detriment of the
medical educator's primary commitment. The 'teachers status' is now becoming
a status symbol to help the competition in private practice rather than as a
vocation of commitment.
The Medical - industrial complex has also made major inroads, in their linkages
with, especially in the clinical departments generally compromising / complicating
the situation further.
27
c) Team Training
The need for profesional training / orientation and skill development in pedagogy
to enhance the educators role of Medical Colelge faculty has been inadequately
stressed in Medical Education with the leadership of medical colleges particularly
failing to understand the scope and the challenge.
The National Teachers Training Centre initially in JIPMER, Pondicherry and at
PGI Chandigarh and BHU, Varanasi have done yeoman service in training some
medical college faculty in modern pedagogical methods, to enhance the quality
of teaching. However, while many faculty have been trained over the years, an
assessment of their impact and contribution leads to identification of two key
lacunae in their efforts:
i) Follow up of the trainees and support to 'critical masses' of trained faculty
in medical colleges, to introduce reform and enhance teaching quality have been
rather adhoc and inadequate, plagued both by lack of finances / resources as
well as lack of college leadership commitment.
ii) More significantly however is the 'myopic' view point that teacher training
means pedagogical change or educational technology per se. The whole issue
of social orientation and relevance of the contents of education and the whole
area of motivation to teach including role-model formation - tackling cognitive and
affective issues have been neglected.
Pedagogical change per se can lead to the ambigious situation of irrelevant
curriculum being taught by relevant methods.
Only when pedagogical change goes hand in hand with 'content change' can the
teacher training make a more definitive contribution towards overall National
Health goals and priorities.
The MCI recommendations of 1981-82, include the suggestion that workshops
should be held for teachers on (a) 'Problem of Community Health and delivery of
Health Care' (b) Methods of teaching and examination. These recommendations
has been mostly ignored.
Teacher training is still not mandatory. In a recent MCI conference - (September
1994) on 'Training Teachers for Tomorrows Needs' some definitive
recommendations towards this goal have however been suggested. The
development of a Medical Education unit or department in every college, the
training of teachers at the time of induction, in pedagogy; aptitude testing for
teaching cadre; teacher evaluation as an integral part of the educational
programme and promotion of student, planning of programmes, are all steps in
the right direction and are fully endorsed by us ( 17 )•
However as mentioned earlier, the content and process of Teacher Training have
to be modified from Pedagogical training to a more comprehensive Reorientation
and preparation, for the Task of being a Teacher. This is one of the crucial
challenges of the years ahead.
28
I
Selection
Linked to the whole issue of teachers, is the issue of proper selection. While
MCI lays down guidelines about qualifications and experience there is no
mention about careful selection based on aptitude or motivation to be a teacher.
This issue needs serious attention.
2.9 ) CURRICULUM DEVELOPMENT / RECOMMENDATION (MCI)
The Medical Council of India recommendations have shown a gradual change
from 1960s to the 1980s, with a fair degree of responsiveness of the council, to
expert committee recommendations towards greater community orientation of
medical education, (see next section). This is particularly significant since
Medical College teachers opposing reform or supporting status quo often use the
"bogey" of MCI recommendations to stall change.
The MCI recommendations broadly include:
i) Guidelines for teaching including more objectivity, flexibility, small group
orientation, less didactics and more problem solving, field involvement and skill
training.
ii) Selection factors being modified with further positive bias towards
underprivileged.
iii) The main emphasis, increasing importance and wider ambit to the teaching
or Preventive and Social Medicine (now extending from first year to final year in
most colleges).
iv) Introduction ot a wide range of topics in various subjects to keep medicos
abreast with developments in the medical / health field. These have included
virology, clinical pharmacology, family planning, demography, nursing, genetics,
nuclear medicine, biophysics, space medicine, electronics, molecular biology.
v) Rural / Community postings in Compulsory Rotating internship after the final
examination.
vi) A suggestion for orientation / training and involvement of all faculty in rural /
community health.
vii) Some examination changes - mostly additional subjects like Microbiology
Paediatrics, ENT, Opthalmology.
viii) Additional clinical postings in TB, leprosy, psychiatry, casualty and
emergency departments.
While these are all mostly in the right direction, a critique of the overall curriculum
development efforts of Medical Council in India focusses on four issues:
29
i) The PSM subject / Department concept has built up a parallel track in which
one department attempts promotive / preventive / social orientation while all the
other departments continue the conventional focus on secondary / tertiary
hospital medicine. The absence of total college faculty involvement in the
process of community orientation is proving to be a serious lacunae and PSM
Departments are particularly reaping the counter productivity of the reform
efforts.
ii) With increasing involvement in rural / urban communities and field practice
areas beyond the teaching hospitals a few medical colleges have been involved
with health and development processes and greater involvement of community in
decision making and management. A shift from PSM to 'medicine in the
community' and to the next phase of empowering community to the responsibility
towards health (community health) is required, if this reorientation process has to
make an impact on new health attitudes in the doctors, as preparation for the
future. The PSM framework of MCI has been seen to be somewhat of a
constraint in this much needed transformation.
iii) Training in new pedagogy has not been mandatory; so most medical college
teachers continue the didactic culture of their own teachers, most of whom had
not received any training either.
iv) MCI has been too keen to keep the Indian medico upto date with advances in
medicine. While many things are added nothing has been deleted or modified.
So the pressure on the medicos have actually increased and the focus towards
primary health care challenges diluted by all the additional high tech topics and
updates.
v) Finally there is very little examination reform in medical education so that all
the suggested changes do not get reflected in exam reform, and fail to be taken
seriously by students and faculty together.
However we would reiterate that in spite of the above lacunae the MCI curricular
recommendations of 1982 now applicable to colleges, gives adequate
opportunity to all college faculty to creatively innovate within the overall
constraints of conventional subject classification and examinations and are not
altogether a constraint for change.
The gross lack of knowledge among medical college faculty of the actual MCI
recommendations themselves may perhaps be a greater constraint.
30
2.10) COST / FINANCING OF MEDICAL EDUCATION
Costing and financing of Medical Education in the country has been a topic,
greatly neglected by policy makers and researchers. It had been estimated that
the investment on every medical student for the entire phase of training was
anywhere from 80,000 to 1 lakh - the range being because of varying
expenditures being included in different ways by the researchers. However
these estimates are all outdated (mostly 1970‘s) and have not been updated.
However, the wider question of who finances medical education in India and
how, is still inadequately understood except for some observations from the
preliminary studies of FRCH (1989).
These studies have shown that the Government till more recently has been the
sole investor in Medical education (wholly financed by the public exchequer from
tax revenue collected from the people). More that 70% of doctors trained by
governmental institutions take up private practice. About 30% migrate to other
countries especially the developed countries of the west. Public resources are
therefore being used for the benefit of the private sector in the area of Medical
Education !
More recently there has been an unbridled growth of capitation fee medical
colleges especially in the states of Karnataka and Maharashtra. Apart from
being closely linked to a pheonomenal, commercialization of medical education,
the problem is worsened by the abettment of the governments, in not only
providing tacit approval in spite of stated National and state level policies against
such colleges, but also in providing clinical facilities and other benefits to these
colleges, who make no investments in the health services of the state.
The recent Supreme Court judgement suggesting that the government subsidise
the students in private colleges and even provide soft loans to them is further
adding to the earlier mentioned problem of public subsidy for private sector
expansion. The move to re-label this group of institutions with the more
respectable label of 'self financing institutions', and the confusion caused by the
central government policy initiative to secure private sector support to higher
education efforts by the state, has made the situation more ambigious.
It is important to note that with the years, the costs of medical education and
health care are escalating rather than falling and hence greater clarity in
investment in medical education and seeking alternative avenues of support
rather than direct commercialisation through donations / capitation fees will be a
major challenge to the government. The recent move at both Central and State
levels to introduce NRI quotas of the capitation fees variety' in Government
colleges is therefore a most retorgressive step supporting commercialization'
rather than 'responsible privatization'.
While a public - private mix may be unavoidable, costing / financing of medical
education will have to be subject to rigorous policy studies in the next few years,
so that government efforts are primarily directed to produce adequate human
MP'igo
31
f/^ (
and
iENTAT'0*
_y
J
power for state-run services and get over the imbalance and acute short fall in
the situation of production and enrolment of nursing and allied health
professionals.
Medical Education has dominated the health human power development efforts
for too long and provided inadequate returns. A time for more rational planning
which is need based and data based is urgently needed. Training of Doctorsjs
only one of many tasks in health human power development. This sense_Qf
proportion in efforts need to be re-established.
2,11) CORRUPTION IN MEDICAL EDUCATION
Corruption and graft have become the bane of public and private life in India and
have crept into all sectors of development and human endeavour. Medical
Education is no exception.
While the more obvious 'commercialization' of medical education - the capitation
fees problem has been mentioned in earlier sections there are more insidious
aspects of corruption that have seeped into all aspects of this sector as well.
Influence of money power and power politics in the selection of candidates for
medical college admission; and in the examination results at various levels; are
now becoming commoner.
Misuse of funds for personal aggrandisement or for improperly sanctioned
institutional or departmental development; extraneous influences in promotions
and transfers and the cancerous growth of private practice values in patient care
within government hospitals are all manifestations of the problem.
While at the level of anecdotal and often experiential evidence, there is adequate
data on the problem, it is surprising how reports and studies undertaken by
professional researchers and numerous internal and external reviews, fail to
highlight or even mention this fall in ethical standards in medical colleges. One
wonders whether the 'conspiracy of silence' has a professional / class bias as
well.
The problem is further worsened by the active involvement of medical college
leadership and the seniors in the Medical profession - many of whom by virtue of
being compromised personally, are unable to take a public stand against the
issue, Even if they do so, it is often a blatant double standard.
Media reports and as mentioned earlier, some committed student sponsored
collective action seem to be the only attempts to counter or atleast bring some
public scrutiny and pressure on the system, to tackle this problem.
A major study that is recommended urgently to understand the full implications of
this degeneration of the medical education sector is the in-depth study of the
nexus between
a) the medical - industrial complex; and
b) the 'capitation fees' lobby of medical colleges
32
with the political and professional health leadership and policy makers in the
country. Only then will it be able to fathom a major paradox in the Medical
Education situation in India, in recent years i.e., the mushrooming and totally
unregulated growth of capitation fees colleges and the fall of ethical standards.
inspite of central and state governmental level and professional association level
stated policies against this type of commercializatiorL
Any quality control or applications of norms and standards to ensure traininq_of
well oriented and skilled human power including doctors in the country will come
to naught if this major factor for degeneration of professional standards is not
adequately researched and countered through effective legislation and other
control measures.
2.12. MEDICAL STUDENTS - PROTEST MOVEMENTS
An important phenomena in Medical Education process has been growing
involvement of medical students and junior doctors in collective action - protests
and strikes.
On a superficial overview, this may be seen as a sort of trade-union activity at
junior doctor or medical student level to improve their own facilities and their
allowances, etc., but a deeper analysis shows that the student and junior doctor
community have shown a much more vigorous social concern than the teacher
or 'medical' professional community and the issues for which collective
democratic protest action have been initiated have included:
i) Concern and action about privatization and commercialization of medical
education (the whole recent, Supreme Court case against capitation fees
colleges was initiated by student action). The recent Kerala students / medicos
strike has also been on the same theme.
ii) Corruption in medical colleges, especially around selection and
examinations.
iii) Concern about falling standards or inadequate facilities.
iv) Adhoc policy decisions in response to politically strong pressure groups.
v) Against harrassment of students by teachers in examinations and even
generally
Teachers on the other hand have mostly agitated for better pay and sometimes
improved facilities, showing a lack of broader social concern.
While the involvement of students / teachers in democratic protest action that
could affect patient care in teaching hospitals has been a subject of some public
debate, the growing and wider social concern and vitality for action of the
medicos must be noted with appreciation. This should also be harnessed for
promoting changes in the curriculum framework towards greater social
relevance, as well as countering the disturbing trends described earlier.
33
2.13) POSTGRADUATE COURSES:
The country has a large network of medical colleges that also offer a wide range
of postgraduate courses in a wide variety of preclinical, paraclinical and clinical
disciplines apart from an increasing range of public health / primary health care.
However the overall emphasis of postgraduation has been towards specialist and
super specialist training for secondary and tertiary care and not towards public
health and primary health care needs.
The following observations are pertinent:
i) The number of seats and courses around Public Health and Primary Health
Care form a very small part of the overall investment in post graduate medical
education (see table - of supplement).
ii) Public Health training centres like AIIHPH - Calcutta, AFMC - Pune and others
have grown very marginally. The transition from Public Health1 departments /
institutes of the past to PSM Departments' presently and From Diploma courses
in Public Health to MD courses in PSM have not led to greater field involvement
of young medical graduates in practical 'public health action'. On the whole it
can be concluded quite definitively that public health as a speciality has been
neglected greatly and allowed to degenerate due to lack of support and
investment.
iii) There are no courses in General Practice, Family Medicine, MCH care, etc.,
which would have been supplementary support to public health care efforts.
iv) Most if not all postgraduate courses in basic and clinical sciences do not have
adequate modules or units of primary health / health care relevant issues so
even the support that can be provided by secondary / tertiary care providers for
primary health care efforts is not enhanced at postgraduate levels.
v) A few medical colleges have initiated such options and linkages with varying
degrees of success but in the overall, this has been an area of policy neglect.
vi) Many well known projects, institutions and coordinating centres, voluntary
health sector have evolved very practical training programmes in community
health to reorient and prepare doctors and nurses and others for community
health work. These experiments have not been taken seriously by the main
stream due to inadequate efforts in dialogue between the medical college
trainers and the trainers in the voluntary sector.
An effort to bring about such an interactive dialogue is a crucial pre-requisite for
strengthening of PHC oriented PG Training in the country.
34
TABLE 13
SPECIALITY WISE SEATS AVAILABLE IN POST GRADUATE MEDICAL COPSES IN INDIA
SPECIALITY
SEATS AVAILABLE
ADMISSIONS
DEGREE / DIPLOftt 1978-1979
DEGREE /
DIPLOMA
X
1) PRE AND PARA
CLINICAL <
1082
612
12.8
2) CLINICAL «
4718
3659
76
3) COMMUNITY /
PUBLIC HEALTH
633
487
10
TOTAL
SOURCE : 2
4
WWOMY, PHYSIOLOGY, BIOCHEMISTRY, MICROBIOLOGY, PATHOLOGY, PHARMACOLOGY,
BIOPHYSICS, APPLIED BIOLOGY, BASIC MEDICAL SCIENCES, VIROLOGY, MYCOLOGY
«
MEDICINE (GENERAL), SURGERY (GENERAL), OBST. AND GYNAC, FORENSIC MEDICIIE
ANEASTHESIOLOGY, 0PTHALMDL06Y, CHEST DISEASES, ORTHO PAEDICS, PAEDIATRICS,
RADIOLOGY, PLASTIC SURGERY, THORACIC SURGERY, PSYCHIATRY, PHYSICAL MEDICINE 6
REHABILITATION, CARDIOLOGY, NEURC0L06Y, OTORHINOLARYNGOLOGY, VENERI0L06Y 6 DERMATOLOGY
GASTR0ENTRQL06Y, GENITO URINARY SURGERY, SPEECH AND HEARING, MEDICAL LAB TEDKICIAN,
ENDOCRINOLOGY, IMMUNO )¥£MAT0L06Y AND BLOOD TRANSFUSION, NEPHROLOGY, UROLOGY, MASTER OF
DENTAL SURREY
PREVENTIVE AND SOCIAL MEDICINE, CHILD HEALTH, PUBLIC HEALTH, OCCUPATIONAL FEALTH,
HOSPITAL ADMINISTRATION, WJTRITION, MATERNAL It CHILD HEALTH, INDUSTRIAL HEALTH,
HEALTH STATISTICS, IEALTH EDUCATION
35
2.14) CONTINUING EDUCATION
The efforts of the government to provide continuing education to the doctors,
nurses trained by medical and nursing colleges and para-medicals trained by
health and family welfare training centres and other institutions have been very
very inadequate and in some regions nearly non-existent.
The estimates today are that professional knowledge changes drastically within
6-7 years requiring regular professional updates if health teams are to be kept
informed and skilled for the challenges they have to face.
Except for some programmes organised by the IMAs, CMC Hospital, Vellore;
NIHFW, New Delhi; and occasionally by some of the medical colleges in the
cities continuing Education is still to take off in any meaningful way, inspite of all
the policy rhetoric.
Most health professionals in the field are hopelessly out of date and receive
technical information and updating, if at all through the commercial information
efforts of medical companies and drug producers, which by their very nature,
would be inadequate and biased.
The recent development of the Open University concept and the growing
enthusiasm for the distance learning concept as well, provides a new opportunity
for Continuing Education of the health team to become a possibility if these
mechanisms are adequately harnessed by health policy makers and health
human power developers. However, there is a tendency in this sector as well to
cater to the creation of new courses and new cadres without adequate policy
policy formulation for the continuing education of all those who have already got
their basic training but need urgent updates, to keep them professionally
competent. If this preoccupation with 'basic education' rather than 'continuing
education' continues, then it would perhaps be a major opportunity missed !
GOALS OF MEDICAL EDUCATION SOUTH EAST ASIA REGION
Ik qoaI (or ReorIentatIon ol MecKca! EducAiioN (n tHe souih East Asia
is tUat by tUe year 2000, aK mecKca! schools in tIie REqioN will Be
pRoduciNq, ACCORdiNq TO tBe NEEds ANd RESOURCES of tIte COUNTRY,
qRAduATE OR SpECiAliST doCTORS, who ARE RESpONSivE TO tIiE SOCIaI ANd
SOCiETAl NEEds ANd who POSSESS ThE APPROPRIATE ErhicAl, SOCIaI, TEchNiCaI, SCiENTific ANd MANAqEMENT AbiliHES SO AS TO ENaBIe ThEM TO WORK
EffECTivEly iN ThE COMpREhENsivE hEAhh SYSTEM bASEd ON pRiMARy hEAhh
CARE which ARE bEiNq dEVElopEd iN ThE COUNTRIES of ThE REqioN.
- WHO -SEARO
ROME Booklet No. 1
'36
2,15) MEDICAL COUNCIL OF INDIA
Much has already been mentioned in this report on the contribution both positive
(through recommendations and guidelines setting) and negative (through default
or lack of regulatory teeth) of the Medical Council of India, which was set up and
continues to exist to maintain standards in Medical Education in the Country.
A very important basic problem in the framework of the MCI structure is that
since Education is a state subject in the constitutional schedules and hence the
primary responsibility of the states and their universities, MCI has in principle a
recommending function only, not a regulatory one.
While MCI recognition is mandatory if a degree from one state university is to be
reciprocally recognised by other states / university, the ambiguous situation
arises when a state / university can continue to recognise a medical college
locally, even if it is not approved or recognised by MCI.
State recognition is more easy to manipulate due to power politics and other
extraneous factors whereas central or council level manipulation is more remote
as a possibility.
Thus the reform of the MCI structure to make Medical Education a national
subject and give it adequate powers to regulate standards is crucial. The MCI
Act of 1987 which was in the statue books for years and was not passed
probably due to various lobbies has now been superseded by the Government
Ordinance of 1993 which has then become subsequently an Act as well. This
has put a damper on the capitation fees sector but a legal battle is still on
regarding what to do with colleges that have already been in existence and have
batches of students under training, etc.
The MCI is now the sole authority supervised by Central Government to provide
recognition to any college and or to new courses.
An important factor which is however not yet built into the Act / ordinance and
needs to be done soon is the whole issue of granting autonomy to some pace
setter institutions to experiment with newer alternative options in Medical
Education.
While supervising and maintaining general standards for all colleges, this
granting of autonomy will be a stimulus for much needed creative and alternative
thinking that is needed to make the present MBBS course more relevant.
All over the world the concept and experimentation on Alternative Tracks and
experimental parallel curriculum are going on in full swing, with an International
network of these efforts sponsored by WHO and other agencies, actively
networking and supporting the change process. India has lagged behind even
though within the constraints of MCI framework major changes have been
attempted by some colleges (see next section).
37
Many 'alternative track' ideas have also originated in the Indian milieu though in
the absence of actual experimentation, they are still hypothetical.
The MCI organised two important conferences in recent years which have shown
a greater understanding of the needs and challenges ahead. The workshop on
Need based Curriculum for undergraduate Medical Education in New Delhi,
August 1993, and the workshop on Training Teachers - today for tommorrow's
needs, New Delhi, September 1994, have made salient recommendations (see
next section).
It is a pity however that on the subject of the 'Alternative track' MCI
recommendations from the former conference have reiterated that "since the
changes proposed in the MBBS curriculum would take care of the kind .of
competency suggested in the alternate pathway, as such there is no need for the
same".
A further qualifying statement in the same recommendation - "However, the MCI
may permit and encourage innovative educational reforms for providing inputs for
introducing curriculum change" is a chink in the armour and we hope, will be an
opportunity to push this idea at a later date.
2.16) EXPERT COMMITTEES AND POLICY REVIEWS
Since the 1970s, there has been a growing concern about the situation of
Medical Education in the country and the relevance and nature of its growth.
This was part of a broader concern about the inadequacies of the health care
delivery system that had been built up in the first three decades since
Independence.
a) The Group on Medical Education and Support Manpower (known popularly as
the SRIVASTAVA REPORT ) was set up in 1974 because "Medical education in
India over the years has been essentially urban oriented, relying heavily on
curative methods and sophisticated diagnostic aids, with little emphasis on the
preventive and promotional aspects of community health
Although the
number of doctors has steadily increased over successive plan periods, the
alienation of the doctors from the rural environment has deprived the rural
communities of total medical care."
The group made a detailed analysis of the situation and recommended some far
reaching changes which included among others:
i) Community orientation of undergraduate medical education;
ii) Curriculum revision; adoption of suitable teaching methods; examination
reform; improvement of facilities in medical college; preparation of teachers and
so on;
iii) reform of teaching hospitals and integration into a national referral system
complex with peripheral health centres and smaller hospitals;
38
iv) reorganisation of the pre-medical course and the compulsory rotating
internship
v) provision of continuing education;
vi) evolution of a national system of medicine by development of an appropriate,
integrated relationship between modern and indigenous systems of medicine;
vii) studies on medical manpower need.
The Committee also recommended the development of a Medical and Health
Education Commission to coordinate and maintain standards in health and
medical education.
The main contribution of the Srivastava Report was the beginning of a dialogue
about the inappropriate pattern and framework of medical education and the
direction towards alternative programmes.
b) In 1981 a study group set up jointly by the Indian Council of Social Sciences
Research and Indian Council of Medical Research to evolve an alternative
strategy for the Health for All goal echoed the concerns of the Srivastava Report
by noting that
’ There is little congruence between the
role of the physician and the needs of
society; little equilibrium between medical
education and health care1.
While endorsing the overall recommendations of the Srivastava Report, this
expert group made some relevant additions as well:
j) it categorically opined that there should be no new medical colleges and no
increase in the intake of existing medical colleges and no need either to set up
new or additional institutions to train additional doctors through short term
courses.
In the new model that the group proposed, it was estimated that "we needed
around 250000 doctors and we already had an existing stock of 220000 and an
annual increase of 13000. So there was a danger of over production^
ii) It suggested the abandonment of the flexnerised model and the development
of a community oriented model to produce a more relevant community oriented
physician.
iii) It emphasised greater skill development in the course and suggested
enhancement of the doctor's role in training / assisting health teams, health
education and epidemiology.
39
iv) To enhance the 'empathy with people' factor, it suggested that candidates
with social and cultural backgrounds closer to the people and from
underprivileged groups were to be selected.
v) It emphasised the need to integrate medical education with health care
services.
vi) It emphasised the need to evolve an appropriate income, wages and prices
policy and to improve service condition of doctors and health workers.
The ICSSR / ICMR study group probably made the most concerted
recommendation towards the search for an 'alternative'. However, this was lost
in the formulations and policy processes that followed.
c) In 1982-83, the Government of India announced a Comprehensive National
Health Policy - for the first time since Independence. The policy clearly stated
" The prevailing policies in regard to education and
training of medical and health personnel, at various
levels has resulted in the development of a cultural gap
between the people and the personnel providing care".
It identified that effective delivery of health care would depend very largely on the
'orientation towards community health of all categories of medical and health
personnel1 and exhorted that:
II
... the entire basis and approach towards medical
and health education, at all levels, is reviewed in terms
of national needs and priorities and the curricular and
training programme restructured to produce personnel
of various grades of skill and competence, socially
motivated to effectively deal with day to day problems,
within the existing constraints".
It then went on to reiterate the need for formulating a National Medical and
Health Education policy which would:
i) identify the changes required;
ii) provide human power production guidelines;
iii) seek to resolving sharp reigonal imbalances; and
iv) ensure that all personnel at all levels are socially motivated towards the
rendering of community Health services.
d) In 1986, the National Education Policy was announced by the newly created
Ministry of Human Resource Development. While it did not specifically include
higher education, its framework committed to social justice, human values, equal
access; core curriculum promoting democracy, secularism, egalitarianism,
scientific temper, gender equality, environmental sensitivity and small family
norm; thrust to open and distance learning and continuing education; promoting
40
autonomy; improvement of pedagogical skills and examination reforms and
greater role of communities, voluntary agencies / NGOs and social activist
groups in educational efforts are all relevant. It was clear that if there was
adequate political will to operationalise this framework, Medical Education reform
would have a larger supportive social framework.
e) The draft National Policy on Education in Health Sciences (1989), which was
circulated for debate, brought together all the concerns and suggestions that
have been evolving since the late 1970s and endorsed.
the earlier recommendations about the Education Commission in Health
Sciences;
linkages between health care delivery and education in health sciences;
the interaction between the practioners of the allopathic and other systems of
medicine;
the importance of continuing education;
faculty development processes including establishment of regional teacher
training centres; and
health human power planning which is data driven.
Its recommendation to make medical education more humanistic, nationally
relevant and socially committed were particularly significant. These include:
i) " a power balance between technological and humanistic medicine;
ii) a more holistic approach covering pormotive, preventive, curative and
rehabilitative aspects of medicine;
iii) a proper balance between the tertiary care hospital - based and primary care
community - based education;
iv) a shift of emphasis from the use of teacher-oriented to learner-oriented
methods which would include self-directed learning and self-evaluation;
v) a progressive change from a narrow discipline - oriented teaching to a
problem - oriented approach;
vi) a shift from theoretically -oriented teaching to experimental learning;
vii) a major shift in the medical teachers' role from imparting a defined quantum
of knowledge to that of a facilitator and motivator of community - based student
learning".
f) Finally, the Eighth Plan document has endorsed all the recommendations of
previous expert committees and a crucial policy component included in the
approach document is:
41
1
" Reorientation of medical education to make
it problem centred and community based"
thus emphasising the two most critical components of change in the 1990s.
The later 1970s and the whole of the 1980s have thus seen regular policy
exhortations and endorsements for radical change in medical educatiort
However while there is a supportive environment at policy formulation level, the
social environment and context in which medical education efforts exist and grow
are very different as exemplified in some of the earlier sections,
. ................. .
I
"A basic doctor, to effectively deliver 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
fora positive health action work The action domain
ofthe doctor has crossed the boundaries of drugs and
dispensaries and presently extends to a large extent
to the famHies and to the communities - hence the
need for the basic doctor to be a community physi
cian*.
- Draft National Educational Policy for Health Sciences (1989).
42
;
..J
PERSPECTIVES IN MEDICAL EDUCATION
3. APPROACHES TO TREATMENT
In the previous chapter, we have described the reality of medical education
which is both disturbing and thought provoking and emphasised the broader
context in which Medical Education reform and reorientation have to be situated.
The picture however is not all bleak. The growing spirit of introspection and
dissatisfaction has led to some experimentation, and innovation in medical
education in a small number of institutions all over the country where critical
masses of committed faculty have attempted to go beyond diagnosis of the
problem to some forms of treatment.
This chapter explores the salient features of some of these experiments.
3.1. THE KOTTAYAM EXPERIMENT (1976)
This was an experimental project organised by Prof. Jacob Chandy (a well
known Neuro Surgeon and Medical educationist) from 1972-76. The project was
a fore-runner for alternative curriculum efforts and though it is not as well known
as it should be, because of inadequate documentation and communication, it
showed that with adequate will, commitment and imagination, experiments such
as
as this
this were
were possible
possible on
on the
the Indian
Indian scene. Not surprisingly, it was not taken very
seriously by the Medical establishment and though it did inspire and stimulate
many other health human power development courses by various Southern
state governments, an opportunity to build further on the experiment was missed
in the specific context of Training of Doctors.
, 19^
I9&l
I;
1
I975
I970
|98l
19^^
-Tuf
CC^UH
S,t
I'
i
COM^U
j
:, pm7siC'A
poc-r^
! ^,AU
i R^SP^fAur>AL'AE
i 8HDCrf
I etpe^L
i
pa’'E'kT
physic
lor
ncAinH
c Ap-b
ltsSLrH«‘AU-
^2^>-
rEpo^-
43
iiY
PH-ys'0'
I
T
COMMUNITY NURSE? ALTERNATIVE DOCTOR?
THE KOTTAYAM PROJECT
The Kottayam Project (Kerala), set out to train a new category of health worker who
would act as a liaison between the doctor in the hospital / clinic and the community
- taking care of comprehensive health needs directly or through the supervision of a
team of paramedical workers.
The role for the Community Nurse' as she was to be called, included Health
Educator. Family Welfare Worker. Medical Assistant and Health Supervisors.
Nine girls from a lower socio-economic group with pre-university qualification were
taken through a three year six semester community based training programme,
conducted by a team of two doctors and a nurse, who instructed them in all the
subjects and were supervisors of all the learning experiences .
The curriculum evolved by class room interaction of perceptors and students on the
feedback from community experience which began from the first semester itself.
A fixed team of examiners drawn from conventional medical college examined the
students at the end of each phase and the final examination was attended by a
Government of Kerala Evaluation team as well. All the candidates except one was
found adequately prepared for their role in the community and the examiners agreed
that they w^ere better than the 'average medical intern' or public health nurse from
the conventional colleges. After a year's internship in which 6 months were spent in
community health work and 6 months as health educators in village schools, the
eight community nurses' were absorbed by Mission hospitals of the CSI Madhya
Kerala diocese to continue community oriented work' in outreach areas of the
hospitals. The keyword of the experiment was integration and community
orientation' at all levels
However three southern states governments adopted the course outline
and elements of the experiment for three grades of health workers. Kerala for B.Sc.,
Public Health (Community) Nurses Training: Tamil Nadu for Health Assistants
Course; and Andhra Pradesh (Osmania University) for B.Sc., in Health Sciences
geared to training teachers of schools in Education for Health Programmes
.
44
II
3.2. THE ROME EXPERIMENT (1977)
This experiment of linking medical colleges with three primary health centres
each and of providing mobile clinics to facilitate the provision of an extension
clinical service by teaching hospital faculty in the designated PHC areas was a
major effort of the government in the late 1970’s. The project was not only to
reorient medical education to primary health care needs but also to link medical
education with health service development. This had already been pointed out
as a major lacuna in Medical Education development in the country.
While the project was well conceived, the implementation gap was rather wide
and it was unfortunate that the programme became counter productive to its,
original aims and gradually was neglected in most states of the country.
However it was probably the only programme of its kind applied to the entire
medical college sector and in that context there are many positive and negative
lessons to be learnt, especially if the entire experiment was seen as an active
learning experience to evolve more comprehensive and more feasible
programmes in the future.
The 1981 Evaluation by GOI showed that District hospitals were not adequately
involved; faculty members other than PSM Department were not adequately
involved; state, regional and institutional level committees were not adequately
operational; referral systems between periphery and other levels were highly
unsatisfactory; the mobile clinics were under utilised due to shortage of staff; lack
of supporting transport to carry students; inadequate funds for fuel; and logistical
difficulties were experienced in taking these vehicles to interior villages.
The ROME Experiment
A GOI Initiative
The ROME (Reorientation of Medical Education) Scheme was launched
in 1977 to introduce and opportunity for community orientation by
students and teachers of medical colleges in India.
The general objective was to involve the medical colleges in the
community health problems and in direct deliveny of health care
services to the rural population.
The specific objectives were to expose students and faculty members to
rural environment: upgrade the quality of health sendees in rural areas
by providing expertise and specialised assistance: taking responsibility
of promotive, prevenUve. rehabilitative and curative health care of 3
Community Development Blocks in the beginning and later covering
the entire district within 3-5 years. . . .
Each Medical college
college was supplied with 3 large mobile clinics to
support the development of this referral services complex.
Guidelines were set for the implementation of the scheme by Ministry of
Health and Family Welfare. It balanced sendee deliveiy provisions with
teaching / training recommendations. 105 Medical colleges and PGI
Chandigarh accepted the scheme.
45
In 1985 a National Workshop on ROME Scheme identified the following
additional needs to enhance the impact of the scheme: Staff orientation course;
additional transport to take students and faculty; expediting accommodation and
other construction works; additional staff; preparation of educational materials,
better communication between peripheral centres and medical colleges, flexibility
in programme to suit institute needs and community needs; continuing education
and research efforts to build into the scheme.
An important overall lesson from the ROME Scheme process was that it had to
be backed by
i) a concerted reorientation / sensitisation programme for faculty to avoid
'professional disinterest' and apathy;
ii) A well planned resources management exercise to prevent bureaucratic
inefficiency since the experiment was affected greatly to both these factors.—In
the final analysis a lack of both these factors adversely affected the experiment
over the years.
3.3. DEVELOPMENT OF THE HEALTH UNIVERSITY CONCEPT
The 1980's have also seen the development of the 'Health University' concept
bringing together medical colleges primarily and other health manpower training
institutions and teaching hospitals under a single technical university jurisdiction.
Tamilnadu already has one and so also Andhra Pradesh. Karnataka and other
states have proposals under consideration. While the objective has been
primarily administrative reform and standardisation of curriculum and facilities,
the 'Health University' concept has great potential if its sponsorrs can explore the
idea with greater creativity (see box).
CHALLENGES FOR A HEALTH UNIVERSITY
A network of community health enthusiasts in Karnataka State had
placed a memorandum before the expert committee exploring potential
challenges for a Health University project which included :
- social sciences orientation,
- community oriented field training,
- pedagogical training for teachers.
- small group / participative and interactive learning
experiences.
- bridge / option selective courses between disciplines and
systems of medicine,
- curriculum research,
- vernacular bias,
- removing gender bias, and
- radically altering the curriculum of all grades of health
manpower
CHC, 1988 ( 24 )
46
I
The health university could bring together gradually, medical colleges, nursing
colleges, rural health and family welfare training centres, specialist institutions
and teaching hospitals, institutions of other systems of medicine and interact with
other departments of the general university as well. The scope is enormous but
centralisation could also have its own problems including the further
marginalisation of health / medicine from the general educational system and the
domination of the hospital oriented clinical faculty on all efforts at all levels.
3.4. MEDICAL COLLEGE INITIATIVES
A few medical colleges have made serious efforts to operationalise some of the
ideas and expert recommendations, and some have gone further to evolve their
own community oriented training strategies. While most of this reform is within
the framework and structure / function determined by MCI regulations, it does
represent a very healthy and experimental trend. Except for two or three medical
colleges where the 'critical mass' of both committed faculty and experimental
initiatives have been large enough to make some impact on institutional, staff
and student orientation, in most other situations innovation has been episodic,
adhoc and not adequately sustained by leadership.
However they do represent a wealth of ideas and experiences to build upon
further and in that sense they are a definitive contribution to the ongoing quest
for the right type of training, to produce the basic doctor the country needs.
A study undertaken by the Society for Community Health Awareness, Research
and Action from April 1990 - December 1992 (22 ) identified 50 initiatives that
represent this experience.
These can be classified into six broad thrusts which form an integral part of the
re-orientation process.
3.4 a) Thrust: IMPROVING PEDAGOGY OF MEDICAL EDUCATION
An important area of innovation and reorientation has been the
attempt to clarify objectives at institutional level and departmental
levels (instructional); and improve the skills of staff in modern
educational techniques. This helps to make the process of education
more rational and meaningful both to the students who are the clients
of the system and the staff or faculty who are the facilitators of the
system. Initiatives are of various types and have been experimented
with, to greater or lesser extents in a few colleges (see box).
47
IMPROVING EDUCATIONAL PROCESS
Defining Institutional Objectives
Defining Intermediate (Departmental) and Instructional objectives
Development of Medical Education Cell with adjunct faculty
Faculty Training Programmes in Medical education skills
Selection Procedures including Psychological tests / Social Skills /
Leadership skills / Value orientation
Curriculum development including integration, identification of core
abilities, and skills.
Examination Reforms
Faculty / student involvement in Medical Education / research.
Tutorial system
' • meetings
"
on Curriculum issues and SocialRegular faculty - student
Societal issues.
Continuing Medical Education
Internship Assessment / Evaluation.
Narayan, R, et al, 1993 22 )
While improvement of pedagogy1 in Medical Education is an important step - this
is not sufficient since it has to be balanced with a concurrent change in content
as well towards greater social and community relevance.
48
3,4 b) Thrust - MOVING BEYOND THE TEACHING HOSPITAL
The exploration of greater community based learning opportunities facilitated
primarily by the department of community medicine / preventive and social
medicine, that was created in each college by the early 70s is an important
development.
These helped to provide experience at primary health care level but also
opportunities of training in institutions other than the teaching hospital.
Among all the thrusts, this group of initiatives was probably the most difficult to
operationalise because the process, the experience and the demands
challenged the established value systems of medicine; the culture of medical
education; the urban middle class aspirations of students and faculty and the
ingrained enthusiasm for high tech / foreign medicine.
However in terms of approaches and options this group of initiatives does
represent a large common - sensical response to the idea of a medical college /
hospital without walls - allowing community needs and aspirations to gradually
stimulate student and faculty to new ways of thinking.
Of all the experiments included in this group, two have shown specific promise.
The Community Orientation Programme or Rural Orientation Programme
beginning in the preclinical year is a stimulus to the young medical students to
understand community dynamics (community anatomy and community
physiology) concurrently with his exploration of human anatomy and human
physiology.
The community based posting during the Rural internship is a summative
experience providing him / her an experience of community based general
practice / family medicine / community health.
Some dynamics of both these innovations are described in illustrative case studies.
49
a
MOVING BEYOND THE TEACHING HOSPITAL
Community - based orientation programmes (preclinical)
Urban - slum based multi - disciplinary student programmes
Community Based Family Care Programmes /
Family Health Advisory Service
Community Block Posting (First Clinical Year)
Rural / Urban Slum health visits / camps
Community Block Posting (2nd Clinical Year)
Epidemiological / Public Health Projects
ROME Scheme
Peripheral Hospital Postings - TB, Leprosy. Eye Hospital. Rehabilitation Centres.
Isolation Hospital, infectious diseases. District / Peripheral Hospitals
Community Health postings in Rural / Urban field practice areas
Community based camps / clinics by clinical departments
Posting to Government PHCs and sub-centres
Involvement of interns in special situations - Epidemic control. Disaster relief.
Plantations, Health Projects by voluntary agencies. Immunization programmes. FP
motivation programmes.
Narayan, R. et al 1993(22)
// X
to
COMMUNITY
QRiENTEP
I
J"
^BEHAVIOURAL SCIENCE
BIOiTAmTlCS
ANATOMY _
/ PHYSIOLOCiY
ECOLOCY
leaixmhip
SKILLS
6I0CHEWUTR.Y
—----------------- —| YA LUE
OR-IE-NTATION
SOCIAL ANALYSIS
N U T RITI ON |
--------------- TCOMMUNI CATO H
NURSING
HOSPITAL
I---------Community orientation fTC.
50
INITIATIVE: RURAL ORIENTATION CAMPS
A group of thirty pre-clinical medical students camp out in a village
school in Karnataka with a few staff members of the Department of
Community Medicine. The camp has a double purpose:
i) To get to know the social anatomy and social physiology of rural India
and
ii) To explore individual motivations, values and perceptions in a wider
social context.
The ethos of the camp is based on group dynamics and participatory’
planning. During the two weeks, the students go out daily in groups of
two’s and threes to visit families in the neighbouring villages and elicit
information about various aspects of village life, through informal
chats. The first week focuses on community dynamics - agriculture,
occupations, village government, health and education facilities,
markets, transport and communication; the second week on family
dynamics - caste, culture and religious traditions, festivals, maternity
and child health practices and KAP towards folk, traditional and
Western medicine alternatives.
During the two weeks, discussions are organised with village leaders,
school teachers, health and development service providers. Students
interact with village youth and school children in informal education
programs and participate in village events and festivals.
The focus of all the concurrent small group discussions is not only the
"what” but also the "why” so that the deeper social dynamics are
explored. Since many of the medical students, by nature of the
selection process, are urban, middle - class youth, cross cultural
conflicts and class prejudices in the interpretation of observations and
in the evolving perceptions have to be tactfully challenged. Though
simulation games, the complex life conditions in which the rural and
urban poor operate and make decisions is experienced.
The two week experience increases social sensitivity and provokes
medical students to look beyond the medical college walls to existing
social realities.
- Narayan, R. ( 25 )
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51
T
INITIATIVE : RURAL COMMUNITY HEALTH CLINICS
Interns, who have completed a few months of hospital based internship
are posted for three months in teams of two, to small, rural community
health clinics in villages. These clinics are organised by the staff of the
Community Medicine Department, through mobilization of resources,
initiative and involvement of the village communities and development
agencies. The resource mobilization is multi pronged: finance through
cooperatives, festival donations; contributions from banks and payment
for services; labour; provision of clinic accommodation; accommodation
and facilities for young doctors; time and participation of formal and
informal leaders for decision - making meetings; volunteers and so on.
The interns participate in all these efforts.
They are supported by weekly supplies of drugs, information, morale,
cold chain, sterilized equipment, by visiting staff members. A weekly
MCH clinic is run by departmental staff. The interns are encouraged to
organize school - based health programs, training in health and first
aid for village youth, health-education programs, specialist camps.
Initiative is primarily left to the interns, while visiting staff are merely
facilitators.
The programs wax and wane with the varying motivation of the interns
and staff but the open-ended approach promotes initiative and
enthusiasm. Each intern undertakes a village based project - a survey
or exploration of a health problem. The focus, due to time constraints,
is more on methodology' and home contact than on findings.
The principle and ethos of the program is to view the intern as a
participant in a process not a cog in the wheel'.
Many are challenged, many are enthusiastic, but all experience the
stark realities!.
- Narayan, R.
52
( 25 )
f
3.4 c) THRUST : WIDENING HORIZONS
Introducing new concepts, and topics as sub-units of existing subjects or as
additional subjects to widen the horizon of the future doctor and prepare him for
involvement in Primary Health Care and community based situations, is another
important group of initiatives. There has been a wide range of ideas and
experience (see box).
1I
!
WIDENING HORIZONS
• Introduction of New Subjects like Behavioural Sciences,
Ethics. First Aid. Nursing. Integrated Growth and
Development.
* Improving interpersonal skills and communicaUon with
patient
• Reorienting Pharmacology7 Training towards Rational
Therapeutics. Essential Drugs Concept, and greater
Clinical Orientation.
• Special Training Programmes in Epidemiology,
Biostatistics, Health Education, Clinical Epidemiology,
Management, Health Economics.
* Training in Emergency Medicine. Social Paediatrics,
Social Obstetrics, Clinical Pharmacology.
* Internship training in specific additional skills in
Rational Drug use.
i)
Management
ii)
Ethics
hi)
Health Education
iv)
Epidemiological Projects
v)
Clinical research.
vi)
I
Narayan, R. et al 1993 (22 )
While the Medical Council of India has endorsed a few of these - its list of
additions have included a large number of topics aiming at keeping medical
students abreast of all the new dimensions of high-tech medicine and
advancements, that primarily focus on secondary and tertiary medicine. These
have included genetics, nuclear medicine, biophysics, space medicine,
electornics, concepts of molecular biology, etc.
With the goal of producing of the 'Basic Doctor' or the physician of the first level
of care, it is important that some criteria for selection of areas to be included
should be used to prevent the introduction of further minutiae to over burden the
already overburdened medical student.
53
A time has also come to clarify that preparing doctors for Primary Health Care is
very different from preparing doctors for Secondary / Tertiary care and therefore
not only the mix of subjects but the areas of additional focus may have to be
clearly demarcated. The 'include everything', philosophy cannot any longer be
justified.
3.4 d) THRUST : IMPROVING SKILL DEVELOPMENT
An important area of initiative is to enhance the skill development aspects of
medical education, the neglect of which has been found to be a serious lacuna in
the existing process. The medical student is so overburdened with lectures and
practicals mostly at the cost of learning experiences at the bedside of the patient
or with the community. The internship is often the first level at which the medical
college graduate begins to develop skills and confidence in decision making on
'purposive clinical intervention'. This too has been often sidelined by the
pressures of clerking. Attempts to provide opportunities for inservice training and
acquring skills through graded responsibilities in actual procedures (see box) will
be a major contributer to the production of more confident Primary Health Care
providers in the future.
IMPROVING SKILL DEVELOPMENT
Improving interpersonal and communication skills (Preclinical)
Junior Clinical Clerkship (1st Clinical year)
Senior Clinical Clerkship (2nd clinical year)
Posting in general outpatient / general practice departments (GOPD)
Clinical Clerkship in Primary’ Clinical Departments
Community based camps / clinics by clinical departments
Internship orientation programme in rational presecribing
Involvement of Interns in Primary Health Care Training of Health
workers. Dais, Auxiliaries.
Internship training in special clinics in Hospital situation - Curative
General Practice Unit / GOPD, etc.
- Narayan, R. et al, 1993 (22)
54
3.4 e) THRUST : TRANSCENDING COMPARTMENTALIZATION
Many efforts have been made as shown in the box to integrate subjects and
phases of teaching in medical education at different levels and get over the
compartmentalization that has been a historical development. While the attempt
has been to coordinate / integrate different subjects and aspects of teaching
around specific systems of the body or health-medical problems - the effort to
transcend (see box) compartmentalization has been hampered by the subject
wise classification of disciplines in the medical college and the structured
framework of phases and examinations built inflexibility into the system as an
MCI recommendation.
It is not surprising therefore that these attempts have not been able to move
towards the two 'radical changes' in the curriculum now integral part of the
curriculum in the more pioneering centres of the world and i.e.,
i) Integration of the preclinical subjects into the teaching of an Integrated
Human Biology;
ii) Shift from a subject / system orientation to a total problem based and problem
solving orientation in the clinical years.
While some expert recommendations have been made towards this goal and the
Consortium of Medical Colleges and others have explored the alternatives at the
conceptual level there is much more efforts required in this area of thrust.
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TRANSCENDING COMPARTMENTALIZATION
• Foundation Course for entrants in group dynamics,
values orientation, linkages between basic sciences and
health care communication and learning skills,
educational objectives, etc.
* Community - based orientation programme (Preclinical)
to study Community anatomy / community physiology
• Humanisation of pre-clinical practicals
• Hospital visiting to make students attentive listeners,
compassionate, skilled communicators
• Synchronisation of para-clinical subject lectures with
clinical teaching
* Integrated teaching in para clinical and clinical subjects
and Clinico-Pathological-Social Case Conferences.
* General Practice Outpatient Department(GOPD)
* Interdepartment Coordinated Clinics in Hospital
Programmes - under five. Family Welfare clinics, etc.
* Interns orientation programme including
development and basic management perspectives.
skill
Narayan, R. et al, 1993 ( 22 )
3.4 f) THRUST : PROMOTING SELF LEARNING
Some initiatives in the direction of promotion of self-learning by students has
been made (see box) but this is probably the weakest area of innovation in India.
It has its roots in a top-down heirarchical teacher and university centred
educational system that sees students as passive recepients or clients of a
system rather than active participants or collaborators.
Medical educators and experts, have an overall confusion between the terms
'teaching' and 'learning'.
56
PROMOTING SELF LEARNING
Student Electives
Students involvement in Research
Involvement of interns in special situations
ii) Disaster relief
i) Epidemic control
iv) NGOs Health Projects
iii) Plantations
vi) FP motivation
v) Immunization programmes
Rural (Placement) Scheme
Narayan, R. et al, 1993 (22 )
Improving opportunities for students to decide for themselves; exploring areas
independently even outside the curriculum; and involvement in determining the
pace of learning even in the established curriculum; are areas of change, being
experimented in very few centres of excellence.
In the Indian situation, however, the experimentation has met with some
difficulties at the student - expectation level. Because of the structure / nature of
the pre-medical educational process and tradition, students are not used to
making their own decisions about 'learning' and 'process'. They are not always
ready for taking on the independent initiative or responsibility that is the core of
any effort to stimulate self learning.
The premedical experience has often converted them into passive recipients and
they resist efforts or opportunities to become active participants.
This is an area of challenge in the years to come.
To recapitulate them, an overview of Medical college initiatives, mostly restricted
to a small number of (less than 20%) colleges in the country have shown that a
multiprolonged effort to reorient medical students in India in the years to come;
will have to consist of pedagogical changes; moving beyond the teaching hospital
to the teaching community; widening horizons; improving skill development,
transcending compartmentalization and promoting self learning. The challenge
will be to initiate and sustain these thrusts over the next decade.
57
3.5) GRADUATE FEEDBACK
What do young doctors who have managed to reach 'Primary Health Care1
projects or small peripheral hospitals and health centres have to say in terms of
their own feedback on Medical Education? This was the important focus of a
complementary study that was done by CHC (1993).
The dialectic tensions, faced by these young graduates in health care service
situations, for which they were inadequately prepared by the existing 'medical
education’ system, led to some 'gut level' and very frank suggestions which could
prove very useful to medical educators. This pilot survey was particularly
significant since the graduates had two years field experience in the realities of
Primary Health Care.
The summary of the salient findings of the survey are shown in the box:
r
GRADUATE FEED BACK - 1
AREA FOR SKILL DEVELOPMENT
i) Basic Nursing Procedures
ii) Emergency Medicine
iii) Minor Surgical Procedures
iv) Obstetrics
v) Local Anaesthsia
vi) Running a simple Laboratory and Pharmacy
vii) Basic Management Skills
viii) Basic Communication skills
ix) Assessing Community Health Needs and evolving
simple strategies
x) Training Health Workers
- Narayan, T, et al, 1993 (23)
58
GRADUATE FEED BACK - 2
SUGGESTIONS FOR MODIFYING
CURRICULUM STRUCTURE / FRAMEWORK
i) Introduce integrated teaching focusing on common problems
ii) Reduce unnecessary detail in theory
iii) Reduce Pre-Clinical phase to 1 year
iv) Teach Sociology / Psychology / Nursing Procedures in
6 months gained from pre-clinical reducUon
v) Increase responsibility and decision making capacity in ward
work
vi) Long and short postings - stress importance of both
vii) Final MBBS / Internship postings in ancillary hospital
departments:
Pathology laboratory / pharmacy / records department / blood
bank / accounts section
viii) Final MBBS / Internship - involvement in training of health
workers
- Narayan. T. et al, 1993 (23)
This was probably the first time that consumers of medical education were giving
feedback after experiencing work in situations of primary care. The study also
moved from empiricism to practical experience and demonstrated that structured
interaction and data collection process from the medical graduates who are
performing the functions intended in the objectives of under graduate medical
education is a useful guide to curriculum development and the reform process.
Faculty in medical colleges would be greatly benefited if this feedback
mechanism from the consumers of the education system was part of a
continuous monitoring system introduced to keep faculty in touch with the
realities at the primary health care level.
59
3.6. THE COMMUNITY HEALTH TRAINERS OF THE VOLUNTARY SECTOR
A study on the large network of Community Health Trainers of the voluntary
sector in India lead to the identification of many innovative ideas and
methodologies used by these training groups which are significant for medical
education reform as well. This significance is particularly so, since many of
these training programmes have evolved processes and methodologies to
reorient doctors and nurses and other health workers who have had basic
training in the existing orthodox institutions but are then attempting to run
services / projects in the voluntary sector.
The major contributions of this group of trainers are:
* Experimentation with an alternative philosophy of education which is more
participatory, experimental, learner centred and action oriented.
* Introduction of a large number of 'small group' techniques and methodologies
in the learning process.
* Strong community orientation in the methods since most of the training is
community based and non-hospital oriented.
* Strong social analysis, which explores broader factors in society that affect
health exploration of community / societal responses and initiatives to problem
solution. This is very different from, the preoccupation with individual / medical /
professional problem solution, which is the current orientation of orthodox
medical education.
* Focus on skill development especially those important for community based
work viz., planning, organisation, communication, health education, training of
health workers, community diagnosis, needs assessment, participatory
management, evaluation, etc. There is greater emphasis on learning by doing.
* Greater learner centredness with participants of training programmes involved
in planning and giving shape to learning experience through feed back, much
more deactively than medicos in present day Medical Education.
* Exploration of training beyond 'cognitive aspects' to include training in 'affective
aspects' of work / skills eg: value orientation, motivation, self analysis, group
dynamic skills, team work, etc.
* Evolution of numerous case studies, simulation games, role models and other
interesting problem solving and situation analysis learning methods that help
60
participants get a deeper and more relevant understanding of the realities in
which they have to operate in their future work.
Medical educators experimenting with community orientation camps, community
block postings, community based experimental learning, and all field based
learning activities beyond the teaching hospitals can learn a lot from this
experimentation in the alternative sector. This study showed that there are many
groups in the country who have broken out of the traditional / conservative
academic moulds and have experimented with alternatives more responsive to
peoples needs and community aspirations. It is time that medical educators
moved beyond their 'ivory towers' to more actively learn and interact with these
pioneers.
A word of caution
In terms of the studies reported in Section 4-6, while the Medical College survey,
Community health trainers survey and the graduate feedback survey led to the
generation of a large amount of qualitative data on the initiatives towards social
relevance and community orientation as well as practical suggestions for reform,
the field visit observations and the interactive discussions led to the identification
of issues and constraints that determine the long term success or failure of
attempted reforms.
It must be stressed that
* Those involved are caught up in : the dialectics between the needs of Primary
health care and the demands of secondary / tertiary health care; the changing
value system of students and teachers; the established middle class culture of
education; the strong urban practice aspirations and the infectious enthusiasm
for 'high-tech' and 'foreign' ideas.
* While the Medical Council of India regulations are not as constraining a factor
as popularly imagined, an increasing arm chair Community medicine faculty have
not been able to provide adequate inspirational leadership, to get over the
resistance to 'moving out' by rest of the college faculty.
* Inadequate staff selection and orientation have further compounded the
problem.
* Without the realistic stimulus of student and graduate feedback, efforts at
reforms continue to be adhoc and empirical. Total faculty involvement is still a
myth.
61
* Change in the 1990s can be brought about only if all these contributing factors
are tackled with a courageous, dynamic and creative collectivity.
Of all the colleges in the country experimenting with change in the curriculum,
Christian Medical College , Vellore has shown the greatest consistency in terms
of framework and innovation even though all this is within the MCI determined
framework.
The Vellore Model of training ( 26) which has evolved through serious
experimentation, committed introspection and concurrent evaluation needs to be
taken seriously by a larger number of medical colleges in the country. The
introduction of the concept of community block postings at three points in the
medical course - with specific objectives and methodology, followed up by a well
planned internship including a community based phase of posting is nearest to
the 'ideal' recommended by the MCI and perhaps goes a little beyond it. Not
surprisingly the MGR Health University in Tamil Nadu has initiated a process to
facilitate the sharing of the Vellore Model with faculty of other colleges in Tamil
Nadu - to stimulate the development of a commonly accepted framework for
Community Orientation in Medical Education in Tamil Nadu.
3.7)
ALTERNATIVE TRACKS AND EXPERIMENTAL
PARALLEL CURRICULUM
In the absence of the concept of 'Autonomy' in Medical Education in India,
colleges both 'average' or 'pace-setter' have been constrained to stay within the
constraints of a nationally designed and approved curriculum, recommended by
Medical Council of India. While the MCI has organised expert meetings and
conferences from time to time and recommended modifications to the curricula in
response to various expert committee recommendations, and sometimes to the
specific initiatives of some of the pace-setter medical colleges or institutions like
the NTTC, the overall pace of change has been too cautious and often
inadequate to meet the need of our rather different socio-economic-cultural
aspirations and needs.
If improvements have been made possible and there are now many innovative
programmes in many parts of the world, it has primarily been facilitated by the
autonomy of a medical college faculty to try innovative programmes and
experiment with drastic changes and radical departures from the past framework.
The shift from subject classification to integrated Human biology and problem
oriented teaching was one such shift; From Trainer centred teaching to learner
centredness was another such shift.
62
From clinical orientation to community orientation is yet another. Of all the three,
the last one has met with the greatest resistence - but attempts have been made
all the same.
The experience in India in pursuit of the Alternative Track has been varied.
While all the efforts till the early 1980s was geared to reforming the MCI
curriculum towards greater community orientation it is only in the 1980s that
serious hypothetical outlines of Alternative tracks and experimental alternative
curriculum have evolved.
Six initiatives are mentioned as illustrative case studies. All of them are
hypothetical constructs that have not yet been experimented with. But they do
represent a growing 'critical mass' of alternative thinking in the country which
needs to be linked to autonomous initiatives in the 1990s.
If certain selected colleges in the country are given the freedom to try new
experiments, unhampered by national norm regulations and if the selection of
colleges is made properly ensuring that institutions with established credibility in
facilities, standards and quality of education are included, then many of these
hypothetical constructs could be initiated as experiments. Not only would the
trials lead to a wealth of experience but Medical Education reform would receive
major stimulus as well.
3.7a THE JNU PLEA FOR A NEW PUBLIC HEALTH
I
The Jawaharlal Nehru University's Centre for Social Medicine and Community
Health has been a pioneering training experiment in bringing together a dialogue
between bio-medical and social science perspectives in the context of Health
care and Health Human power development in the country. Emerging as the
chief critique of the existing rationale and framework of Health care in India, it
has also raised various conceptual issues about alternative human power
development in the country by offering a new perspective on Public Health /
Community Health deeply embedded in a Social Science perspective of Health.
Its formulations for training the right type of doctor have been tentative but do
provide adequate perspective on the New Public Health concept to evolve an
alternative track.
The concept of a 'managerial physician' who "have epidemiological capabilities to
relate technological interventions to the problems as they exist in the entire
population; who have managerial capabilities to run highly complicated
organisations;
and who have social awareness that will motivate them to
give privacy to the needs of the individuals, families and communities in all they
do
" is the sheet anchor of this alternative framework (see box).
The framework further demands a new social ethos in the medical college
system so that "health personnel are trained to 'go to the people and learn from
them' using the methods and concepts of social sciences. . . , rather than being
sales agents or bureaucrats attempting to impose pre-determined and pre63
packaged programmes on the people ... .". They should also "be able to
organise awareness building programmes that contribute to the promotion of
social control over health services, promote community self reliance and
articulate democratic aspirations of the people in the field of health".
This approach called the 'new health education approach' should "encourage
people to want to be healthy, to know how to maintain health, to do what they
can individually and collectively and to seek help when needed".
The four issues forming part of the educational strategy for producing such
managerial physicians skilled in the new health education approach are outlined
in the box.
!
EDUCATIONAL STRATEGY FOR THE
MANAGERIAL PHYSICIAN (JNU)
I
■
I
f
KEY ISSUES
1) Developing a historical perspective of the democratic
movements and relating it to a historical account of health
service development
i
I
2) Adoption of an epidemiological approach for the analysis
of national health programmes and formulating alternative
approaches
3) Analysis of the politicial economy of health, health
services, population control, maternal and child health,
nutrition and other aspects / components of health service
developments.
i
4) Addition of ecological, social and cultural dimensions to
observe epidemiological and demographic phenomena .. . .
II
I
- BANERJI, 1986 ( 2 )•
I
3.7b THE mfc ANTHOLOGY OF IDEAS
The medico friend circle is a national level group networking, lobbying and issue
raising around the values and approaches necessary for the emerging
Community Health Vision in India and also to counter entrenched medical vested
interests and attitudes not conducive to a people's health care. The group
emerged during the ferment of the 1970's (the emergency and its aftermath).
Over the years this group has brought together people from diverse ideological
backgrounds to discuss issues of relevance to health care and medical education
in the country and through its annual meetings and bulletins, voiced these
concerns and explored alternatives.
64
In the 1980's the group published three anthologies of reflections on Health Care
entitled "In Search of Diagnosis (1977); Health Care Which Way to Go (1982)
and Under the Lens - Health and Medicine (1986)".
The mainfesto of the Circle brings together its key perceptions of the Indian
reality and highlights the stands its members take on a range of health care
issues upholding human values and promoting greater sensitivity and
responsiveness to the needs of the large majority - the poor and under privileged
in India ( See Text).
In January 1991 the mfc published its special anthology focussed on Medical
Education bringing together reflections of some of its members and group
discussions organised particularly at Anand (Gujarat), Calcutta (West Bengal) in
the 1980's.
Chapter 13 of this book is a compilation of ideas arising out of all these
reflections and discussions arranged under the subheadings used in the MCI
curriculum 1981-82. This includes general principles (preamble); objectives of
Education; Admission Criteria and Selection of Students; Duration of Course;
Medical curriculum - overall design, Nature and organisation of Training centres;
Methodology of training; Teaching of Community Health; Selection and Re
orientation of Teachers; Evaluation / Examination; Internship and some
additional features.
This probably is among the most comprehensive alternative formulation of
community oriented medical education in the country and it is hoped that it will
begin a serious dialogue around the development of a concrete alternative or
experimental parallel curriculum.
Some recent developments show that such a process may be feasible in the
1990's. Christian Medical College, Ludhiana submitted this Chapter along with
other papers to the Punjab University with an application for an experimental
parallel curriculum and was given the green signal, but could not start due to an
institutional crisis not related to the experiment.
The coordinator of the Expert Curriculum Development Committee of the Tata
Institute of Social Sciences, Bombay, has suggested the use of this alternative
framework to evolve an alternative course for the Community Oriented Social
Worker!
Other medical colleges have shown interest to explore this framework with their
medical education cell / curriculum committees as well. A group of medical
college faculty participated in a process to respond critically to the issues raised
by the mfc document point by point. The CHC studies mentioned in an earlier
section are extensions of this process.
65
3.7c THE ALTERNATIVE TRACK
The International Network of Community Oriented Health Sciences Institutions a network of alternative track medical colleges in the world initiated a dialogue
with MCI and GOI and WHO to initiate an alternative track in India as an
experimental parallel curriculum.
The proposed curriculum was to be problem based (McMaster University model)
and Community Oriented (GOI's ROME Scheme) and learner centred. The
alternative track was to consist of 7 units of 7 months each - devoted to human
biology, 3 to Primary Health Care and 2 to Tertiary health care. The internship
would consist of 6 months of Rural health care and 6 months in clinical
departments. Both the conventional curriculum and the 'alternative track' would
be compared in their effectiveness in the context of Primary Health Care and
Health for All.
The process was stalled at a subsequent meeting because MCI was unwilling to
grant creative autonomy to a few premier institutions to experiment with this
curriculum.
The process did not begin with adequate understanding of the Indian situation
and was more a top-down cross fertilization of an inadequately tested indigenous
programme and a 'model' transplanted from a very different socio-culturaleconomic milieu. So while the experiment would have been an opening, it had
some structural constraints built into the process as well.
3.7d THE MIRAJ MANIFESTO
The Wanless Hospital in Miraj which was the teaching hospital attached to the
Government Medical College in Miraj initiated dialogue and discussion around a
document called the Miraj Manifesto - which was a gradually evolving framework
of an alternative track through discussion and dialogue with alternative
'frameworks' and experiments emerging all over the country. The Maharashtra
Government gave permission to start the alternative experiment but this too was
stalled due to the Central ordinance banning new experiments with State
Governments sanction in the context of the crisis around the growth and
proliferation of the 'Capitation Fee College1 phenomena.
66
t
3.7e THE MCl'S ALTERNATIVE TRACK
An expert committee set up by MCI recommended an 'Alternative TracK' in the
MBBS course geared to preparation for Family Medicine / General Practice /
Community Health. The committee laid down some objectives and guidelines
and suggested a preclinical track that was similar to the existing one but would
then branch of at the clinical phase to a focussed thrust on Family Medicine and
General Practice. This suggestion was however rejected by the 300 medical
educationists, Deans / Principles and representatives from medical colleges, who
met to discuss 'Need based curriculum' in August, 1993.
The recommendations of this workshop unfortunately included the observation
that "the proposed changes in Medical curriculum would take care of the
competency suggested in the alternate pathway, as such, there is no need for
the same".
3.7f CONSORTIUM OF MEDICAL COLLEGES
Since 1987-88 a Consortium of four medical colleges - AllMS (New Delhi), BHU
(Varanasi), CMC, Vellore and JIPMER, Pondicherry, has emerged in the country
adopting the 'inquiry driven strategy for medical education reform' popularised by
the Centre for Educational Development, University of Illinois, USA, a resource
Centre for WHO on Human power training strategies.
The Consortium has been undertaking action research projects on various
aspects of curriculum reform and pooling its findings at regular meetings to
evolve the framework of a new curriculum step by step.
A few years ago four more colleges were added to the Consortium and the
process is continuing.
While all the colleges are premier institutions in the country and have shown a
commitment to Primary Health Care as well - they are also medical education
leaders because of their long term commitment to high quality curative oriented
training in secondary and tertiary health care.
If the framework generated by the Consortium is to move from ideas to action
then the greatest challenge before the consortium medical colleges is to change
the attitudes of their faculty from the conventional preoccupation with secondary /
tertiary care to active exploration of the challenges of primary health /
community health care.
These six rather different approaches and processes illustrate the growing
restlessness for change, that is beginning to be manifested in a small but
perhaps, critical mass of medical college faculty and health policy activists.
67
Some broad similarities have also emerged (see box). All the institutions
involved in this alternative search are all premier institutions or well known policy
groups, well conversant with the existing MCI framework and yet still keen on an
alternative construct. This development, especially increased in the early 1990's,
is a positive development and perhaps the single most convincing reason for the
urgent need for the concept and framework of 'creative autonomy' that should be
considered by both Government and MCI while keeping up the momentum of
reorienting the existing curriculum in the
majority of the colleges.
A time has come when the government must allow a few 'credible institutions' to
experiment more boldly and more creatively.
Such bold and creative experimentation, may, by 2001 AD. help us evolve a new
track which can demonstrably produce doctors that are more attuned to Primary
health care challenges than the reoriented conventional curriculum.
T
FRAMEWORK OF THE ALTERNATIVE
SOME KEY COMPONENTS FROM ALL THE ALTERNATIVES
• Medical course to produce a community oriented, socially conscious,
primary health care provider.
* Competence and capability in multi disciplinary’ skills geared to
community based action
♦ More than 50% of entire of course to be commonly based and faculty
of all departments to be involved in community based teaching.
i
• Social / value assessment at selection and concurrent motivation /
orientation to community need throughout course
• Problem solving orientation and integration at all levels
* Development of competence and skill rather than mere acquisition of
knowledge.
* Communication. Management, Organisational and other skills for
community work
* Conventional curriculum changed with courage tempered by
flexibility and creativity.
• Strategies evolved through field oriented research and experiments
and constantly evaluated / reviewed by Faculty and student.
68
PERSPECTIVES IN MEDICAL EDUCATION
4. EMERGING TRENDS
4.1 THE SOCIAL CONTEXT OF CHANGE
As we reach the end of the millennium, Medical Education, is at the crossroads.
Quantitative expansion of health infrastructure and facilities for training of doctors
over the last five decades since independence has resulted in a massive 'over
doctored' situation in the country at the cost of a more balanced investment on
development of other members of the health team. Shortages of nurses and
health workers are further complicated by over production of the wrong type of
doctors. The goal of eguity in Health Care has remained as elusive as the goal
of the community oriented physician. In many ways this double failure are linked.
However the country has simultaneously entered a very different phase of growth
with attempts to integrate the National Economy with the global market economy.
A Delphi forecast facilitated by CHC (1992) brought together the views of forty
panelists representing all the disciplines of health care and policy to predict the
broader Economic - Social - Political context of change in India by 2005 and the
emerging Health Scenario in that context. These trends are likely to be the
background in which any reorientation or radical reform has to be situated.
The economic, social and political scenario predicted has been summarised.
Both negative and positive (see box) trends are highlighted.
The most important development in the 1990's is however the New Economic
Policy which involves a major programme of economic liberalization and reform
to enhance the role of market forces; provide a larger economic space for the
private sector, and aim at a closer integration of the domestic economy with the
global economy.
The programme of economic reforms aim at higher growth rates and
enhancement of resources to deal effectively with the challenges of poverty
reduction and human development. However until these reforms are well
underway and stabilised the costs will be high including cuts in employment and
in investments in social sectors and infrastructure, and health care or medical
education will be no exception. While the government has denied that these
reforms will affect the health budget or that of related sectors like Family Welfare,
Women and Child Development, Welfare Education and Rural Development,
their own policy statement express this anxiety. The India Country statement of
the Department of Family Welfare (Govt, of India) at Cairo (Sept. 1994) notes,
"There are real risks to the poor from the reforms; adjustment hurts before it
helps. Labour is laid off before growth creates more employment. The long run
success of the adjustment programme and of India's fuller development reguires
much greater attention to human resource development.
69
In the context of population stabilization and sustainable development, it is the
more important to break the nexus between hight fertility, poverty, ill health and
poor education."
Health human power development planners have to locate their initiatives in this
challenging social context.
!
INDIA - 2005 AD
I
i
I
I
A DELPHI FORECAST (NEGATIVE TRENDS)
Economic Trends:
Privatization with Commercialization (including health care)
Decrease in government spending (including health and social services)
Increasing marginalization of poor landless and unorganised groups
Increasing cost of services - diagnostic and curative
Social Trends
Progressive erosion of values
Increasing breakdown of families
Increasing urbanization / marginalisation
Increased violence - regional, ethnical, linguistic, caste, communal
Increased mental ill heatlh - unrest and helplessness
Increased use of tobacco and alcohol and abandonment of traditional food
practices and traditional systems of medicine
Political Trends :
Political instability
Increased political corruption
Decreased national autonomy
Narayan, T., et al 1992 (
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INDIA - 2005 AD
A DELPHI FORECAST (POSITIVE TRENDS)
Economic Trends:
i
Greater Professionalisation in Hospital and Health Management and
development of Health Insurance as a means of third party payment.
Social Trends:
Increased education of women
Greater focus on ecological and gender with positive impact on Family
Health.
Strengthening of Consumer Protection Councils
Increased litigation in the Health Field.
Political Trends :
Awakening of Dalits, tribals and backward classes and increased
participation in political processes.
Greater decentralization and Panchayati Raj.
Increased political consciousness and demands for people centred
participatory processes.
Narayan. T. et al 1992 ( 30
4.2 HEALTH SCENARIO IN INDIA
The health scenario forecasted by the Delphi exercise was as follows:
"The health problems of India will show a complex epidemiology in the years
ahead. While we shall continue to have problems of poverty, poor hygiene, poor
nutrition and poor environment, we shall increasingly experience the problems of
development, affluence and modernization. New diseases will come up along
with the resurfacing of older disease problems with newer trends and patterns.
While this 'double burden' of disease will severely stretch our limited resources,
our ability to deal with the situation will be severely hampered by the broader
socio-economic, political, cultural factors emerging on the national and
international scene that will determine our development, welfare and health
policies".
The significant health problems we will have to tackle in the years ahead will be:
1. Nutrition related problems - malnutrition complicated by increasing
chemicalisation and adulteration of our foods.
71
)
2. Water bome diseases including diarrhoea, dysentery, gastroenteritis, typhoid,
cholera, hepatitis B and parasitic infections.
3. Communicable diseases like malaria, tuberculosis, leprosy, kala-azar, acute
respiratory infections and preventable childhood diseases.
4. Non-communicable diseases including heart disease, hypertension, diabetes
and cancer
5. AIDS
6. Problems of mental ill-health including a whole range of stress - related
disorders, psychosomatic and psychological problems, suicides and dementias.
7. Addictions and substance abuse problems.
8. Pollution related diseases including allergies, asthma and other hazards.
9. Disabilities and handicap problems
10. Health problems of the aged.
11. Iatrogenic diseases.
12. Accidents.
These health problems will be further complicated by an increasing number of
issues significant to health and contributing to the magnitude of disease. These
will include:
1. Increasing environmental pollution and deterioration of ecology
2. Increasing challenge of providing basic environmental sanitation.
3. Urbanisation and its consequences / contribution to health of the urban poor
4. Increasing malpractice in medicine and medical care.
5. Irrational therapeutics in the context of a growing abundance of drugs.
6. Problems of increasing population growth coupled with high literacy and
inadequate health resources.
7. Increasing violence in society and its consequences on social health.
72
In response to the challenges of developing and sustaining health care delivery
systems to meet these problems and tackle these issues, the following will
become significant for the planning process in health care.
1. Health care planning will have to meet the challenges of priorities; equity;
limitation of resources; rural - urban disparities; clarifying the role of technology;
access; and the roles of government, private and voluntary sectors.
2. Costing and financing of health care will become crucial in the context of the
market economy. Commercialization and issues such as cost-effectiveness, self
financing, affordability and cost escalations will become significant.
3. Human health manpower development will be complicated by inadequate
supplies of the right type of doctors and health team members for primary health
care, side by side with over production and over specialisation of the wrong
categories of health workers for secondary and tertiary levels.
4. A Rational drug policy that will deal with availability, distribution and adequacy
of essential drugs. Side by side with, the control of misuse and overuse of drugs.
5. The challenges of providing basic needs and primary health care for all.
6. The needs, priorities and appropriate choices for secondary and tertiary health
care.
7. Health education to promote positive health attitudes and capacities towards
primary health
8. Integration of medical systems, both western and indigenous.
9. Research in alternative approaches, health behaviour, women's health and
holistic health care.
10. Promotion of holistic health care of positive / wellness model with stress on
five basic dimensions of self responsibility, physical fitness, nutritional
awareness, environmental sensitivity and stress management.
Though the Scenario predicted is rather black, the challenges of developing and
sustaining a health care delivery system to meet these problems will be great
and the most challenging of all will be the task to facilitate the training of the right
type of health teams with appropriate skills, knowledge and attitudes.
The challenge will also be to produce the new doctor - not only oriented and
competent in the demands of Primary Health Care but also committed to the
73
broader issues of decentralization, ecological and gender sensitivity, and
committed to ethical values and human rights in health care.
All policy makers and decision makers will have to be alive and responsive to this
new, emerging situation.
'TTke medical education system and tUe KealiK
care delivery system have eack gone tkeir
separate ways. Tkere is little congruence
between the role of the physician and the needs
of society, little equilibrium between medical
education and health care. Medicine is still
regarded essentially os on enterprise
sci
ence and technology; the physician is the re
pository of all knowledge and dispensation,
specialisation is the hall-mark of progress; and
the training ground is the teaching hospital.
Recent efforts to change this unhappy situa
tion, to produce the 'right' kind of doctor and to
give a community orientation to medical educa
tion have yet to make any meaningful impact
ICSSRUCMR Health for All Study Group, 1981
14
perspectives in medical education
5. PRESCRIPTION FOR CHANGE
5.1 ISSUES IN MEDICAL EDUCATION
To understand the context of the prescription, six broad issues need to be
considered. They form crucial components of a new framework that needs to
evolve in our understanding of Health, Health care and Education for Health.
5.1a THE POVERTY - SICKNESS CONTINUUM
The growing realisaton of the intricate relationship between Poverty and sickness
has be be at the crux of the new response. The poor are also sick and the sick
become poor. At the root of ill health is an inequitous and unjust distribution of
the means to health. All health programmes have therefore to be an integral part
of human development and poverty alleviation programmes. The new doctor
and the health team will therefore have to work in cooperation and solidarity with
all those who seek to develop the community and provide the means and
environment for every member of the community to reach her / his potential.
Community Health and Community development become synonymous with each
other. Sustainable development and health care become interlinked.
5.1b COUNTERING THE VESTED INTEREST IN ILL HEALTH :
The growing commercialization of health care and the growing market economy
related distortions in health care options and health care responses need to be
countered carefully. The ICSSR / ICMR Health for All report warned in the
1980's about the Doctor-Drug producer axis that has a "vested interest in the
abundance of ill health". In the 1990's the doctor has now become an agent of a
much more complex medical - industrial complex which is determined to make
huge profits out of ill health and disease. Unless a strong countervailing
movement is initiated by the government, the health professionals, the health
and development policy makers and the people - the distortions of health care,
already being witnessed, will ovewhelm the systems capacity to respond
meaningfully to the problem of ill health, especially of the marginalised in society.
Health care and Medical Education of the conventional type will then become
increasingly irrelevant to the people's needs.
5.1c EDUCATIONAL TRANSFORMATION:
For too long, educationists and health humanpower development consultants
and experts have been preoccupied with the content of change rather than the
'structure' and 'process of change'. The emphasis has been on changing the
components of the curricula - the topics and nitty gritty of what is taught - often
under the mistaken notion that the irrelevance of the conventional curriculum is
75
primarily a 'content' irrelevance. There is now a growing realisation that medical
education is too teacher centred, too top down, too preoccupied with practice
and too ivory towered. There is an urgent need to change it to become learner
centred, student and situation driven, community oriented and geared to skill
development.
From the 'banking type' of education when facts and minutiae are banked in the
students mind, to be recalled when the need demands it, there is a shift of
emphasis of learning experiences to become problem oriented and problem
solving in their approach, linked to real-life field experiences. This pedagogical
transformation is absolutely crucial for change and in the absence of this
understanding much of the community based experience has been affected by
orthodox educational attitudes - that miss the 'woods for the trees'.
5.1 d FROM EXHORTATION TO ROLE MODELS
As a logical corollary of the earlier issue, teachers of medical colleges have to
become facilitators of learning experiences 'grounded in community realities'
rather than pushers of information 'derived from foreign realities'. This calls for a
careful selection policy and a staff development and promotion policy that
focusses and recognises community service, and community health involvement
as pre-requsites for change. Moving from unconvinced intellectual exhortation,
faculty need to speak from conviction of heart and this is only possible if more
and more of the medical college teachers have actually initiated and experienced
the challenges of health in the community. The process to evolve and sustain
such role models become a critical issue for change.
5.1e COLLECTIVE LEADERSHIP
Much of the change strategies in Medical Education in India have suffered from
the problem of changing leadership; adhoc individualised efforts; and short term
experimentation promoted and supported by a constantly changing medical
college leadership. Deans or professors with commitment manage to counter
the apathy or status guo and encourage some faculty to seriously take up the
issues. However these efforts often wax and wane and the long term response
is nullified by leadership change and leadership neglect. There is therefore need
to contextualise and root change, especially at institutional level to the creation of
a core group of innovators / experimenters working collectively, towards a
change process. The concept of a Medical Education Cell or a core faculty team
symbolising collective leadership facilitating a process of change therefore is an
important determinant. The MCls recent recommendation on this is particularly
significant and should strengthen the hands of all those who seek and are
committed to change. (17)
76
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5.1f THE COLLEGE WITHOUT WALLS.
The weakest link in all current efforts in medical education reform is the efforts to
break down the concrete barrier between the teaching hospital and the 'real - life'
health services that exist beyond. The 'Medical college without walls' that will
enhance the exposure and involvement of faculty and students to the challenges
of health care especially primary health / community health situations is an
urgent necessity. Medical education and the regular health services must be
more closely linked. Students, interns and faculty must become more active
participants in health care initiatives. The health care providers and the medical
college teachers must become a closely interactive team. Contextual
understanding and opportunities for skill development geared to the 'real life’
issues of Health care will be greatly enhanced. Ivory towered
compartmentalisation between 'excellence' and 'relevance' will be erased. All
members of the health team will participate actively in orienting new members of
the health team. Health Service and Medical Education will become part of a
closely interlinked continuum.
5.1q TOWARDS A CREATIVE AUTONOMY
One of the major drawbacks in the present medical education system has been
the lack of the concept of 'creative autonomy'. The MCI in its earnest efforts to
regularise and monitor the standards of medical education has provided
guidelines and recommendations which are often referred to as 'minimum
guidelines'. While it has provided some flexibility for change within its overall
guidelines it has tended to be rather inflexible on the 'examination system'. More
so any form of licence Raj gradually moves away from the original goal of quality
monitoring to the more practical dictates of monitoring rule breakers and
guideline evaders. The whole emphasis is on inspection rather than innovation.
While this has some relevance in the Indian situation, where the fall in qualitative
standards in all aspects of education has been quite extensive and hence
requiring some form of policing, a time has come to release at least a few
institutions out of the 145 medical colleges from this licence Raj and provide
them the ethos and stimulus to go beyond the minimum to innovate and to
evolve experimental parallel curriculum and educational processes that are
radically different from the conventional framework. Atleast 6-10 colleges have
now shown the social and professional commitment to experimentation and the
issues of relevance and they should be provided this new opportunity.
The experimentation could be monitored closely and collectively but the
emphasis would be on 'innovation and networking' rather than inspection and
recognition.
There is enough indication already that in spite of all the distortions and
problems that medical education today finds itself in, there is a growing and
77
I
1
committed group of institutions who would be able to sustain and enhance the
opportunity of creative autonomy if that was provided. What is therefore urgently
needed is not a licence to conform but a licence to experiment.
Are the MCI and, the Planning Commission and the Ministry of Health_and
Family Welfare willing to 'midwife1 this urgently needed experimentation!!
5.2 THE KEY TO CHANGE
Medical Education is at the Cross Roads. Our report so far has highlighted the
complex mosaic of issues that have determined the structure, the content and
the framework of medical education that we have in the country today. These
determinants of change are slowly responding to the new market economy
processes that is fast removing medical education from the apex of a pyramid of
health care and human resource development (responding to the needs of the
large majority of our people) to the apex of another pyramid generated by the
medical - industrial complex geared to the profit making potential in ill health.
Since the 1980’s while the rhetoric has been geared to Primary Health Care,
preventive health care and community participation the policy has been geared
to high tech expensive medicine and the privatization / commercialisation of
health care. However we believe that with hope, optimism and collective
commitment this disturbing trend and distortion can be reversed.
In response to the complex mosaic of factors that are actively distorting the role,
scope, goal, objectives and context of medical education today, we recommend
the following twelve point agenda for action:
1) BAN ON MEDICAL COLLEGE EXPANSION
A comprehensive and total ban on Medical College expansion today till the
controversies and distortions are tackled legally and supported by the
strengthening of the monitoring of standards, structures in the country.
The ban should be further supported by encouraging existing 'mega' educational
efforts (150-300 seats) to reduce number of seats gradually to 100 seats and to
improve standards and quality of their programme.
2) STRENGTHENING OF MCI
The MCI has to be strengthened to control the 'capitation fee' lobby and to make
a more concerted and pragmatic contribution to the issue of falling standards.
While the Indian Medical Council (Amendment) Ordinance of 27th August 1992,
(which became an Act of Parliament in April 1993) has empowered the
Government of India to regulate medical education —, further steps needs to be
taken.
78
a) The first step is to provide a stronger social and community representation in
the perspective setting and decision making bodies of the council so that the
people, the community and the social aspects are given importance and not
made subservient to professional or commercial interests. Social scientists and
people of social standing from other professions, voluntary agencies and
consumers groups could be included in the governing bodies. A mechanism for
nomination and or cooption of such representatives should be considered.
b) The second step would be to make it more a professional body, rather than a
political one by changing the membership patterns of the councils and coopting
professional leadership of established nation and region institutions of training
and research as statutory members.
c) The third step would be to build up a more professional core team at MCI
head quarters that facilitates a more comprehensive data driven process of
decision making by providing the council with authentic and relevant background
material for its deliberations.
d) Simultaneously the State Medical Councils have to be strengthened by similar
steps and reoriented to prevent the slide in standards and the evolving qualitative
distortions.
3. NATIONAL HEALTH COMMISSION
Health Humanpower Development Planning in the country has been a serious
casualty in the health planning process because of the multiplicity of professional
councils and the compartmentalised structure of monitoring and interaction, of
the Health Ministry with the training sector. A National Health Commission that
brings together the apex bodies of all the health professionals and all the central
councils of alternative systems of medicine and the representatives of the key
national training centres and coordinating agencies of the voluntary sector is
urgently required.
The main task of this commission would be to urgently address the key issues
reviewed in the National Education Policy for Health Sciences and initiate a
concerted process of need based and data based, integrated Health human
power planning. A strong multi-disciplinary, professional secretariate to the
commission could ensure that the commission does not fall prey to professional
jealousies, inter council rivalries, or political manipulation.
4) MEDICAL EDUCATION REFORM TO BE STRENGTHENED
The reorientation / reform process that has been evolving since Independence is
the structure / framework of Medical Education in India, and particularly
enhanced since the mid 1970s after the Srivastava Report, should be kept up
and strengthened.
79
While much of the ideas / recommendations have been endorsed by national
meetings of Deans and Principles and by Central Council of Health and
reinforced by numerous expert committees and think-tanks, a time has come to
provide a more concerted supportive supervision to ensure that these
recommendations are operationalised and do not remain on paper.
Our studies (22 ) have shown that atleast a small percentage of colleges have
attempted to put these ideas into practice and have taken many of them further.
The 1982 Guidelines of MCI currently in force need an urgent update
incorporating the best and most relevant of this Indian experience. With the new
Amendment to the IMC Act (1993) there is need to move from Becpmendations’
for undergraduate medical curriculum to 'Minimum requirements in curriculum
structure and framework' for continuing recognition by GOI, MCI and state
councils.
The key areas / issues to be strengthened based on the experience outlined in
the previous chapter are
a) formation of a Medical Education Cell in each college to develop critical and
collective leadership to facilitate the reorientation process.
b) Greater measures to select and develop the right type of faculty to enhance
the reform process (aptitude testing at time of selection; training in pedagogical
skills; community / social orientation and sensitization; motivation to be role
models; community experience, etc).
c) Selection procedures - to move beyond selection from PUC marks, to state /
central level examinations, complimented by other selection criteria including
interview, value assessment, aptitude testing, ban on capitation fees as a means
of selection.
d) Stress thrust areas including
j) Widening horizons in rational therapeutics; Alternative systems of
Medicine; Health economics and cost consciousness; mental health; health
management skills; communication skills, etc.
ii) Transcending compartmentalization through greater vertical and horizontal
integration at all levels.
e) Improving Pedagogical skills and learning environment
i) Improving Pedagogy of Medical Education by Faculty training in modern
techniques and methods for which many more National Teacher Training
Centres (NTTCs) will need to be established.
80
ii) Improving opportunities for skill development by providing greater time for
inservice training including graded responsibilities in actual hospital
procedures and community services to allow skill development.
I
iii) Promoting self learning through greater learner centredness in teaching
process and provision of elective opportunities in the hospital and
community.
f) Making internship more skill based and task oriented
51 EXAMINATION REFORM
A thorough review of the examination process at all levels of the course is an
urgent necessity if reform / reorientation process have to be structurally
supported. There is urgent need for MCI to involve Medical Education experts to
evolve guidelines for examinations and examiners which can be ratified by
Universities and gradually operationalised into the curriculum framework.
In addition, internal evaluation processes should be strengthened and a healthy
balance struck between formative and summative evaluation.
Rationalising 'Examination systems' and bringing in a greater consonance
between 'examination' and the 'reorientation' process would possibly be the
single most important step to sustain / consolidate the change process. Two
steps would be particularly relevant.
i) Bringing in safeguards that prevent the operation of money / political
influence and other malpractices.
ii) Proper selection and orientation of examiners to prevent irresponsible,
unethical and irrational patterns.
6) establishing; a framework for creative autonomy
Within the framework of the IMG (Amendment) Act, 1993, there is urgent need to
evolve a framework for creative experimentation which would allow
operationalisation of experimental parallel tracks. These curriculum options
should specifically be geared to Primary Health / Community Health / Family
Medicine / General Practice.
Some 'ideas' and alternative frameworks have been discussed earlier.
81
There are enough pace-setter colleges and institutions that have demonstrated
these professional competence and social commitment who could be given
selective and creative autonomy to experiment with these alternatives. These
experiments could be closely monitored and evaluated, to establish, whether the
graduates of these new experimental curriculum are more community oriented
then those from colleges following reoriented orthodox MCI curriculum.
7) CONTINUING EDUCATION
Urgent efforts to initiate distance learning processes directed to all existing
members of the Health and Allied Professions and particular PHC health teams
are needed. Thsi will get over the serious problem of health teams being
inadequately informed and inadequately skilled, consequent to the explosion of
knowledge and the fast changes in professional perspectives.
IGNOU and its regional branches should be involved in this process with close
collaboration with the professional associations in the country.
A scheme to link continuing education to professional accredition / registration
and service promotion should be introduced.
8) POSTGRADUATE EDUCATION
i) There is urgent necessity to ensure that all post-graduate education, be it in
basic or clinical sciences should have a strong social and community orientation
linked to National Health Policy and HFA goals. Modules dealing with these
aspects must be made complusory in all courses.
ii) Public Health training in the country should be enhanced quantitatively
involving all the public health training / research institutes and those departments
of preventive and social medicine / community medicine that have shown a high
degree of professional excellence and relevance. Practical DPH / DIH courses,
perhaps upgraded to MSc programmes should be encouraged rather than the
more theoretical MD courses.
ill) A serious review of the Public Health System in the country should be
undertaken to explore and consider the development of an All India Public Health
Cadre on the lines of IAS to provide professional and technical leadership and
impetus to National Health Policy and programmes in the country.
The expansion of 'Public Health Training' suggested earlier could be integrally
linked to the creation of the I PH cadre.
82
9) RESEARCH IN HEALTH HUMAN RESOURCE DEVELOPMENT TQ BE
PROMOTED
There is urgent need to ensure that Health Human Power development in the
country including Medical Education Reforms and Reorientation are based on
practical field and action research. The attempts of the 'consortium' of Medical
Colleges to determine the change process through inquiry and short term
research strategies is particularly relevant. MCI, ICMR, NAMS, and IAAME and
other such national organisations should urgently pool their resources and
expertise to create a network of Researchers in Health human power
development, to enhance the policy evolution and policy implementation process.
Many urgent studies that would delineate existing problems and identify
operational reforms can be outlined, e.g:
i) The growth ot capitation fees colleges and the resultant distortions in policy.
ii) Who pays for Medical Education - How will future funding of Education be
operationalised / enhanced?
iii) Implications of privatization / and New Education Policy on Medical Education.
iv) Brain drain - extent, process, implications and correctives.
v) Corruption in Medical Education System - patterns - process - correctives.
vi) Skills, knowledge, attitudes required at Primary, Secondary and Tertiary
levels.
vii) Health human power needs including requirements of doctors / specialists
and allied health professionals at all levels - central / state, etc.
10) REGULATION OF PRIVATE SECTOR / PRIVATIZATION IN HEALTH
CARE / MEDICAL EDUCATION TRENDS
There is an urgent necessity to set up a National 'think tank', committee or some
such review mechanism to undertake a detailed study of the Private Sector jn
Health Care and Medical Education in the country. The study should explore all
aspects of the growth of this sector to assess its existing and evolving
contribution. The study should also identify the negative trends; the problems,
this sector faces in making a contribution to the national effort; and means by
which its efforts can be regulated by the development of standards and technical
guidelines.
83
ll
11) BEYOND DOCTORS - TO HEALTH TEAMS OF PHC’S
Doctors and their training having dominated the health human power sector for
too long and have produced major skews in priority and perspectives. It is
important to establish a changed sense of priority and focus on the Nurse, the
Health workers of the Primary Health Centres and the Community based Health
workers including Traditional Birth Attendants as a major policy shift. There is
need for rigour, concerted effort and serious reorientation, strengthening and
quality enhancement in the training of all these cadres of the Primary Health
Care Team if Health for All goals have to be achieved. In terms of focus of
reform and the reorientation in the training of all these cadres the general thrusts
would be very similar to that outlined for Medical education earlier. But efforts to
initiate dialogue, encourage experimentation and enhance skill development and
social / community orientation is a major challenge especially if the 'cultural gap'
identified by the National Health Policy 1982 between providers and receipients
is to be bridged.
12) THE PEOPLE'S 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, the people in the whole debate. Bringing
Medical Service under the perview of the Consumer Protection Act has been the
first of the required changes. Promoting public debate, review and scrutiny into
the planning dialogues 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 activists, 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.
AH those concerned about 'peoples needs' and 'peoples health' will have to take
on this emerging challenge as we approach the end of the millenium. Our efforts
today, will determine, whether in 2000 AD, 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?
84
I
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Development of Modern Medical Education in India
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2.
Health and Family Planning Services in India - An
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M.C.I. (1987)
3.
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Indian Medical Council, New Delhi.
C.B.H.I. (1987)
4.
Health Information of India, 1987.
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I.S.H.A. (1989)
5.
Present stock of Health Manpower and Projected
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Goya! Kaushal, (Ed) (1990)
6.
Directory of Medical Colleges in India
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F.R.C.H. (1990)
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Health Care Services in India
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Mukhopadhyay J.K. (Ed) (1994)
8
Statistical Outline of India -1994-95
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Health Information of India -1991
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10.
Directory of Medical Colleges in India
COSMOS Book Hive (P) Ltd., New Delhi.
11(a). W.H.O.-SEARo (1988)
Reorientation of Medical Education : The Rationale
and Vision Publication No.18, Booklet No.1
WHO-SEARO, Regional Office, New Delhi.
11(b). WHO - SEARO (1988)
Reorientation of Medical Education - Goals Strategies
and Targets.
WHO-SEARO Regional Office, Publication No.18,
Booklet No.2. New Delhi.
C.B.H.I. (1985)
12.
Compendium of Recommendations of various
Committees on Health and Development (1943-75)
Central Bureau of Health Intelligence, Directorate
General of Health Services, Ministry of Health and
Family Welfare, New Delhi -110 001.
Bajaj J.S. (1994)
13.
Education in Health Sciences - Relevance and
Excellence. I.J.M.E., Vol.33, No.3, P12-23.
Bajaj J.S. (1994)
14.
Quality and Equity in Medical Education
I.J.M.E., Vol.33, No.3, P1-7.
15. ICSSR/ICMR, (1981)
Health for All - An Alternative Strategy, ICSSR/ICMR
Study Group report, Indian Institute of Education,
Pune, 1981.
M.C.I. (1993)
16.
Recommendations of Workshop on Need-based
curriculum for Undergraduate Medical Education -
1.
August 1993.
Medical Council of India, New Delhi.
17. M.C.I. (1994)
Recommendations of Workshop on Training
Teachers today for Tomorrow’s Needs , September
1994. Medical Council of India, New Delhi.
18(a). Duggal, Ravi, F.R.C.h. (1989)
Medical Education in India : Who Pays?
Radical Journal of Health, March 1989.
18(b). Ishi.T.K.
Political Economy of International Migration : Indian
Physicians to United States, p 13-25.
Radical Journal of Health, March 1989.
19. Bajaj J.S. (1991)
National Education Policy in Health Sciences
MME, Vol. 29, Nos. 1 & 2, p35-55 (Jan-Aug 1991)
Narayan, R (1977)
20.
Research in the Methodology of Health
Delivery:Training Programme for Community Nurses/
Health Supervisors (The Kottayam Experiment) A
CSI/FPF project report for Family Planning
Foundation of India, New Delhi.
Narayan,R (1991)
21.
Recent initiatives towards an alternative Medical
Education in Medical Education Re-examination (ed.
Dhruv Mankad) Medico Friends Circle/Centre for
Education and Documentation, Bombay.
Narayan, R et al (1993
22.
Strategies for greater community orientation and
social relevance in Medical Education - Building on
the Indian Experience.
Narayan T. et al (1993)
23.
Curriculum Change : Building on graduate doctor
feedback of peripheral health care experience - an
exploratory survey.
C.H.C. (1988)
24.
Memorandum submitted to Karnataka Government
Committee on Health University.
Narayan, R (1988)
25.
Newsletter of ACHAN, LINK, Vol/ VII, No.1, AprilMay 1988
CHAD - C.M.C.-Vellore (1990)
26.
Teaching Undergraduates Community Medicine
through a Problem Solving Community Based
Approach. Mimeographed booklet, Community
Health and Development Dept., CMC-Vellore,
Tamil Nadu.
Medico Friend Circle (1991)
27.
Medical Education Re-examined (Ed.Dhruv Mankad)
medico friend circle/Centre for Education and
Documentation, Bombay.
Miraj Medical Centre (1988)
28.
The Miraj Manifesto: A proposal for the Christian
Institute of Health Sciences.
Miraj Medical Centre, Miraj.
Consortium of Medical Institutions (1991)
29.
Inquiry Driven Strategies for Innovation in Medical
Education in India (Ed. Kusum Verma, Brian D’Monte,
B.V. Adkoli and Usha Nayar)
(SEARO-WHO Project IND HMD 017.13).
Narayan T. et al (1992)
30.
Seeking the Signs of the Times
A discussion Document, CHAI Golden Jubilee
Evaluation Project, CHAI/CHC, Bangalore.
Supreme Court Judgment on Doctors and Consumer
31.
Protection Act, dated 13-11-1995.
List of Recognised Medical Colleges in India
32.
Medical Council of Indi, 1995
(sent by VHAI-ICHI Secretariat).
85
ii
ACKNOWLEDGEMENTS
To the CHC team especially
Dr. Ravi Narayan, Dr. C.M.Francis, Dr. V. Benjamin, Dr. Thelma Narayan and
Dr. Shirdi Prasad Tekur, for the research and compilation.
To Sri V.J. Jaimon for the tables and diagrams and statistical compilation.
To R. Murali, V.N. Nagaraja Rao, Xavier Anthony, fortyping and
secretarial assistance.
To Dr. Shirdi Prasad Tekur and Mr. Magimai Pragasam for the animation.
To all the medical college colleagues and resource persons,
who have provided ideas during interactive dialogues in recent months.
86
11
LIST OF MEDICAL COLLEGES IN INDIA
(Included in Tables)
ANDHRA PRADESH
1.
Gandhi Medical College .Hyderabad.
2.
Osmania Medical College, Hyderabad.
3.
Andra Medical College. Visakhpatnam.
4.
Guntur Medical College. Guntoor.
5.
Kurnool Medical College.Kurnool.
6.
Sri venkateshwara Medical College, Tirupathi.
7.
Rangaraya Medical College. Kakinanda.
8.
Kakaritiya Medical College, Warangal.
9.
Siddartha Medical College, Vijayawada.
* 10. Deccan College of Medical Sciences, Hydarabad.
52.
53.
54.
KERALA
55. Medical College, Thiruvananthpuram.
56. Medical College, Kozikode.
57. Medical College, kottayam.
58. T.D.Medical College. Alappuzha.
59. Medical College.Thissur.
ASSAM
11. Assam Medical College. Dibrugarh.
12. Guwahati Medical College. Guwahati.
13.
Silchar Medical College. Silchar.
BIHAR
14.
15.
16.
17.
18.
19.
20.
21.
22.
I
Patna Medical College. Patna
Darbhanga Medical College. Darbhanga
Rajendra Medical College. Ranchi
Jawaharlal Nehru Medical College, Bhagalpur
Sri Krishna Medical College. Muzaffarpur
A N Magadh Medical College. Gaya
Nalanda Medical College, Patna
Patliputra Medical College. Dhanbad
M.G.M. Medical College, Jamshedpur
I
I
GUJARATH
23. B.J.Medical College,Ahmadabad.
24. Government Medical College,Surat.
25. M.P.Shaha Medical College, Jamnagar.
26. Medical College, Vadodara.
27. Pamukhaswami Medical College. PO Karam sad.
28. Smt. N.H.L.Manipal Medical College,Ahmadabad.
GOA
29.
I
Goa Medical College,Bambolin(Goa).
HARYANA
30. Maharshi Dayanand University Medical College,
Rohtak.
31. Maharaja Agrasen Institute of Medical Research and
Education.
HIMACHAL PRADESH
32. Indira Gandhi Medical College, Shimla.
JAMMU AND KASHMIR
33.
Governement Medical College,Jammu.
34.
Gov’t. Medical College, Srinagar.
* 35.
Jhelum Valley College of Medical Sciences. Srinagar.
KARNATAKA
36.
Government Medical College, Mysore.
37.
Government Medical College, Ballary.
38.
Karnataka Medical College, Hubli.
39.
Bangalore Medical College. Bangalore.
40.
Sri. Devaraj Urs Medical College,Tamaka,Kolar.
41. Sri. Siddartha Medical College,Turnkur.
42. St John's Medical Collge, Bangalore.
43. Al-Ameen Medical College, Bijapur.
44. B.L.D.E.assosiation's Medical College,Bijapur.
45. Kasturba Medical College.Mangalore.
46. Adichunchanagiri Institue of Medical Sciences
"Vishwmanava ".Bellur.
47. J.S.S.Medical College.Mysore.
48. Kasturba Medical College, Manipal.
49. Jawaharalal Nehru Medical College. Belgum.
50. HRE Society's Mahadappa Rampur Medical College,
Gulbarga.
51. J.J.M.Medical College. Davanagere.
M.S.Ramaiah Medical College, Gokhul Extention,
Bangalore.
Dr. B.R.Ambedkar Medical College. Bangalore.
Kempegowda Institute of Medical Sciences.
K.R.Road, Bangalore.
|
I
I
MADHYA PRADESH
60. Gandhi Medical College, Bhophal.
61.
Gajra Raj Medical College. Gwalior.
62. Mahatma Gandi Memorial Medical College. Indore.
63.
Government Medical College. Jabalpur.
64. Pt. Jawaharlal Nehru Memorial Medical College,
Raipur(MP).
65.
Shyam Shah Medical College, Rewa.
MAHARASHTRA
66. Grant Medical College.Bombay.
67. B.J.Medical College, Poona.
68. Government Medical College. Nagpur.
69. Government Medical College. Aurangabad.
70. Govt. Medical College, Sangli.
71. Dr. V.M.Medical College, Solapur.
72. Swami Ramanand Tirth rural Medical College, Beed.
73.
Sri. Vasantro Nalk Govt. Medical College. Yavatmal.
* 74. K.J.Somiya Medical College. Bombay.
75. Mahatma Gandhi Mission's Medical College,
New Bombay.
* 76.
R. A.Education Society’s Padmashree
Dr. D.Y.Patil Medical College, Bombay.
* 77. Terna Medical College, Bombay.
78. Government Medical College, Nanded.
* 79. Maharashtra Institute of Medical Sciences and
Research, Latur.
* 80. Mahatma Gandhi Mission's Medical College,
Aurangabad.
81.
S. R.T.Rural Medical College. Beed.
82. Jawaharalal nehru Medical College, Wardha.
83. Mahatma Gandhi Institute of Medical Sciences,
Wardha.
♦ 84. N.K.P.Salve Institute of Medical Sciences and
Research Centre, Nagpur.
♦ 85. Jawahar Medical Foundetion, Annasaheb Chudaman
Patil Memorial Medical College, Dhule.
86. Bharathi Vidyapith's Medical College. Pune.
* 87. N.D.M.V.P. Samaja's Medical College. Nasik.
88.
Rural Medical College, (Parvara Medical Trust),
Ahmednagar.
89. Shri Bhausaheb Hire, dhule.
90. D.Y.Patil Education Society's, Medical College,
Kolhapur.
91. Armed forces Medical College, Pune.
92. Indira Gandhi Medical College, Nagpur.
93. Dr.Panjabrao Deshmuh Memorial Medical College.
Amravathi.
94.
Krishna Institute of Medical Siences. Satara.
MANIPUR
95.
N.E.Regional Medical College,Imphal(Manipal).
i
ORISSA
96. S.C.B.Medical College. Cuttack.
97. V.S.S.Medical College, Sambalpur.
98. M.K.C.G.Medical College, Berhampur.
|
PUNJAB
87
99
Government Medical College, Amritsar.
11
UTTER PRADESH
125. S.N. Medical College. Agra
126. Motilal Nehru Medical College, Allahabad
127. B.R.D. Medical College. Gorakhpur
128. Maharani Laxml Bai Medical College. Jhansi
129. G.S.V.M. Medical College, Kanpur
130. King George's Medical College. Lucknow
131. Lala Lajpat Rai Medical College. Meerut
132. Institute of Medical Sciences. Varanasi
133. Aligarh Muslim Univ. Faculty of Medicine
(J.N. Medical College). Aligarh
100 Government Medical College. Patiala.
101. Guru Gobind Singh Medical College. Faridkot.
102. Government Medical College. Chandigarh.
103. Christian Medical College. Ludhiana.
104. Dayanand Medical College. Ludhiana.
RAJASTHAN
105. Sawai Man Singh Medical College. Jaipur.
106. Rabindra Nath Tagore Medical College, Udaipur.
107. Sardar Patel Medical College. Bikener.
108. Jawaharlal Nehru Medical Collage, Ajmer.
109. Dr.Sampurnanand Medical College. Jaipur.
* 110. Medical College. Kota.
TAMILNADU
111. Madras Medical College, Madras.
112. Stanlay Medical College. Madras.
1 13. Government Kllpauk Mdical College. Madras.
114. Changalpattu Medical Collage. Changalpattu.
115. Madurai Medical College. Madurai.
1 16. Thanjavur Medical College. Thanjavur.
117. Tirunelveli Medical College. Tirunelveli.
118. Coimbatore Medical CoUege. Coimbatore.
119. RaJahMuthaih Institute of Health.
Rajah Muthiah Medical College, Annanalainagar.
120. Govt. Mohan Kumaramangalam Medical College.
Selem.
121. PSG Institute of Medical Sciences and Research.
Coimbatore.
122. Perundurai Medical College and Research Centre.
Peundurai.
123. Sri Ramachandra Medical College And
Research Institute. Porur, Madras.
124. Christian Medical College Vellore.
II WEST134.BENGAL
Medical College. Calcutta
135. Nilratan Sircar Medical College. Calcutta
I
136. R.G. Kar Medical College, Calcutta
137. Calcutta National Medical College. Calcutta
138. Bankura Sammilal Medical College. West Bengal
139. North Bengal Medical College. Darjeeling
140. Burdwan Medical College, Burdwan
I DELH!
I
I
t
i
♦ Unrecognised by Medical Council of India
88
141. All India Institute of Medical Sciences. New Delhi
UNIVERSITY OF DELHI
142. Lady Hardinge Medical College. New Delhi
143. Maulana Azad Medical College. New Delhi
144. University College of Medical Sciences and
GTB Hospital. Delhi
PONDICHERRY
145. Jawaharlal Institute of Postgraduate
Medical Education
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