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REORIENTATION OF
MEDICAL EDUCATION FOR
COMMUNITY HEALTH
SERVICES
cniviMiiM"'

COMMUNITY HEALTH CELL
326, V Main, I Block
Korarriongala
Bangalore-560034
India

B. P. PATEL
Secretary,
Ministry of Health, family Planning,

Works, Housing and Urban Development,
Government of India, New Delhi.

HITHER medical education? This is a question exercising
’’ the minds of medical administrators and educationists,
medical profession and the lay public alike in the country.
With the increasing demands of the community for the impro­
vement and extension of health services all over the country
reorientation of medical education has assumed wider signi­
ficance. In the context of the democratic consciousness of
social justice, emphasis on the preventive and promotive
aspects of health in the place of the purely curative care,
and the need to relate medical education to technological
advance and to the conditions of the community have neces­
sitated the reorientation of medical education so as to
bring it in line with the needs of our people, the bulk of
whom live in rural areas. A stage has been reached when
a departure from its conventional pattern and content has
become imperative.
COMMUNITY HEALTH:

INTEGRATED STRUCTURE

The concept of comprehensive health care has formed
the basis of national health programmes. Apart from the
programmes for eradicating or controlling specific commu­
nicable diseases like malaria and smallpox, the core of
it is the programme of establishing a network of primary
health centres to cover the entire rural area of the coun­
try and supplementing it by hospital and referral specialist
services within reasonable reach of the people. Supporting
facilities by way of additional medical colleges, post­
graduate institutes and advanced training in specific fields
in India and abroad have been provided for. Considerable
advance has been made on all these fronts. Nevertheless,
the implementation of the programmes has led to certain
distortions creating in some respects a hiatus between the
objectives of the Health Plan and its actual impact or the
people. For a fuller understanding of this situation ..nd
of the search for remedial measures, to ameliorate it,
the problem needs to be stated in a broader perspective.
Meanwhile, the rapid rise of population has added a new
dimension to the problem of health planning in the country
and to the responsibility devolving on the medical prof­
ession to play its due part in the national programme of
Family Planning.

GROWTH WITH

SOCIAL JUSTICE

The overall objective of our planning has been to
raise the standard of living of the people, particularly
the vast mass of the population living in rural areas.
The function of health programmes is to ensure the physical
and mental well-being of the people so as to raise their
productive efficiency and capacity for enjoyment of a good
life. Successive implementation of the Five-Year Plans and
the ad hoc plans of three single years has brought about
striking advances in many a field. One such achievement is
the success of health measures in controlling or near era­
dication of malaria and smallpox, resulting in a steep fall
in mortality. The longevity has gone up from 30 to 53 - the
addition of one year to the average expectation of life for
millions of our population for each year of Independence.
Nevertheless, the distribution of the fruits of development
has been unequal. Benefits have accrued relatively much
less to those regions and sections of the mass of our popu­
lation particularly in distant rural areas, who need to be
assisted most. The extension of education, health and
medical facilities to rural areas is pain-fully slow, with
the result that the gap between the advantages accruing to
those who are relatively well placed and to those who have
lagged behind tends to widen. There is lately an awakening
to reverse this trend. This is reflected in the recent
directive of the Government to strive for "growth with
social justice".
PRESENT POSITION OF MEDICAL EDUCATION'

. ri

As observed earlier, medical education is among the
programmes which have received much impetus since the com­
mencement of the First Five-Year Plan. The number of medi­
cal colleges then stood at 30 with an adm-i aai on capacity of
2500 students every year. At the commencement of the Fourth
Plan the number of colleges rose to 93 with an annual intake
of nearly 11,700. The number of qualified doctors has
increased by 1*7,000 in less than two decades. The figure on
the registers of the Medical Council of India stood at
1,03,000 in 1969. Even so, this gives a doctor.population
ratio of 1 : 5112 against the objective of providing one
doctor to a population of 3500 as recommended a decade ago
by the Mudaliar Committee. What is disturbing, however, is

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the imbalance in their distribution among the population.
Eighty per cent of the Indian people live in villages and
20 per cent in urban areas, but the distribution of the
doctors is Just the reverse of the ratio of the population
between these two sectors. Still more disturbing is the
reluctance of the doctors to man the minimal of health
services for rural areas. At the commencement of the Fourth
Plan, as many as 508 Primary Health Centres had to be estab­
lished so as to ensure at least one such centre for a Block.
352 Blocks had Primary Health Centres but no doctors. At a
number of other centres, after the doctors are posted their
main preoccupation is to manoeuvre a transfer to an urban
assignment. It would be hardly fair to blame the individual
doctor, faced as he is with the difficult conditions of
living, lack of accommodation and basic facilities of trans­
port, communication and children's education at these places,
and conditioned, as he is, by an urban-oriented education
designed largely to cater to curative treatment in a hospital
setting provided with costly modern equipment and complex
laboratory tests. He is apparently neither trained nor
prepared adequately for the task he is cal 1ed upon to
perform.

URGE FOR NEED-BASED CHANGE

A good educational system should be sensitive to the
social environment of the community which it seeks to serve
and constantly adapt itself to its changing requirements.
Unfortunately, beyond keeping abreast of advances in
scientific knowledge, medical education remains basically
what it was four decades ago when it was controlled and
supervised by the Medical Council of Great Britain. The end
products that come out of medical colleges are understandably
larking in the skills, knowledge and attitudes necessary.to
give community health care in India. Meanwhile, the rapid
rise of population has further widened their responsibility
towards family planning in the interest of the mother's
health, well-being of the family and the prosperity of the
nation. There has been a growing recognition that what is
required to meet the needs of the people of India is a complete, change in the mould of the doctor so that the model
brought out is suited to the conditions of the community.
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MEDICAL EDUCATION

COMMITTEE

In pursuance of the decision of the Central Council
of Health at its 15th Meeting held in October 1968 at Bombay
to evarninp medical education in all its aspects, the Govern­
ment of India appointed the Medical Education Committee of
officials and experts under the chairmanship of Secretary
to the Ministry of Health & Family Planning, Government of
India, to study al? aspects of medical education and training
in the light of the national needs and resources; and to
consider the development of the undergraduate medical
pul 11m in relation to national requirements, the need
for uniformity of syllabus, apportioning of the time between
didactic and practical teaching, selection of entrants to
medical colleges, reciprocity between various medical
institutions and universities and domiciliary restrictions
in the matter of admission to medical colleges.

MEDICAL EDUCATION

CONFERENCE

The Report prepared by this Committee was discussed
in a Conference held in July I97O in New Delhi under the
chairmanship of the Union Minister of Health,Fannly Planning,
Works, Housing & Urban Development. Having been attended
by Ministers, Members of Parliament, Vice-Chancellors, Deans
and Principals, Secretariat and Technical Officers of the
Health Departments of Central and State Governments and
other experts, it was the most representative national
gathering that could be assembled for the purpose.

The Conference debated in depth for two fnl 1 days the
several issues thrown up in the Report and some related items
which were included in the agenda. The conclusion was to
support broadly the analysis of the problem as presented by
the Committee and to endorse its recommendations with some
modifications in matters of detail together with a couple of
recommendations on matters not dealt with specifically by the
Committee. The recommendations of the Medical Education
Committee as modified or enlarged at the Medical Conference
have been accepted by the Executive Committee of the Central
Council of Health at its meeting in July 1970 in Aurangabad
under the authority vested in it co deal with the matter
finally. These recommendations have also been welcomed by
and large by the Medical Council of India. It is a mate -r

of gratification to me personally as the Chairman of the
Medical Education Committee that its recommendations have
received such wide and ready recognition. The stage is now
set for their implementation. I am impelled to write this
article in the hope that it will assist the various authori­
ties and the diverse elements concerned in understanding
them in their true perspective as well as in implementing
them with utmost expedition.
REVIEW OF

RECOMMENDATIONS

It is difficult to do'justice within the compass of
this article to the several, recommendations of the Medical
Education Committee and of the Medical Conference. I would
refer the reader to the Report of the Committee and the pro­
ceedings of the Conferences which have been published
separately for the benefit of the public. I shall attempt,
however, to review briefly the recommendations and comment
on a few important features with a view to highlighting
their implications for the future and to facilitating their
early implementation.
BASIC

DOCTOR

The central theme of the Report is to define a basic
doctor and then to suggest several measures not only to
secure the production by medical colleges of the maximum
number of basic doctors, but to commend to the various
authorities - born governmental and others - to assure for him
an honoured place due to him in the scheme of health admini­
stration and medical profession:
"A Basic Doctor",, says the Report, "is one who is
well conversant with the day-to-day health problems
of the rural and urban communities and who is able to
play an effective role in the curative and preventive
aspects of the regional and the national health prob­
lems. . Besides being fully well-up in clinical methods,
i.e., history taking, physical exam'nation, diagnosis
and treatment of common conditions, he should have
the competence to judge which cases are required to
be referred to.a hospital or a specialist. He should
be able to give immediate life-saving aid in all acute
emsrgencies. ' He should be capable of constant
advancement in his knowledge by learning things for

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himself by having imbibed the proper spirit and having
learned the proper techniques for this purpose during
his medical course".
While taking due care of the selection of talent required
for research and highly specialised skills, the aim of
uedical education should be to maximize the production of
basic doctors who are professionally competent and emotionally
prepared to serve the needs of the community particularly in
rural areas.
AMENITIES AND INCENTIVES

Towards the achievement of the above objective, the
Central Council of Health has recommended that the arrange­
ments of emoluments, amenities and incentives of doctors
should be so devised as to give the balance of advantage to
those doctors who have to their credit adequate service in
rural areas. Specific measures have been recommended to
encourage doctors to go to villages by way of (a) provision
of adequate living and working accommodation in rural areas
fitted with modern sanitary facilities; (b) supply of vehicles
to primary health centres;(c) prescription of minimum service
in rural areas before crossing efficiency bar or grant of
promotions;(d)special medical allowance for service in
difficult areas;(e) opportunities for refresher and advanced
training in India and abroad; and(f) professional contacts
through visits of specialists to such centres.
NO

REVIVAL

OF LICENTIATE OR

DIPLOMA

COURSE

The Committee's recommendation that there is no need
of a diploma or licentiate course in medicine has been
accepted by the Conference, Health Council and Government.
The suggestion of the Medical Education Conference to incre­
ase the training facilities in the existing colleges by
utilising district and private hospitals with adequate
clinical facilities has also been accepted. It is necessary,
however, to point out that there is a strong body of opinion
among doctors and the public that the licentiate course,
being shorter, cheaper and suited to the needs of rural areas,
should be re-introduced to bridge the wide gap between the
requirements and the availability of graduate doctors. It is
their contention that with the cost of producing an additio­
nal graduate doctor of the order- of Rs.80,000/- to the

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community(post-graduate doctor costs much more) and the
J imitation of the projected growth rate of the economy over
the next decade or two, there will be perpetual shortage of
graduate doctors. Secondly, in the situation of overall
shortage, it would be too much to expect that they will
effectively man the rural services. Nevertheless, the
majority opinion has pinned its faith in the proposed
orientation of medical education as well as the commitment
of the profession to meet the needs of the community all
over the country on the basis of improving working conditions
in rural areas. A heavy responsibility rests on those who
have advocated against the introduction of a cheaper course.
Time alone can tell how well they will meet the challenge.
Should they fail, it is obvious that this question will
have to be re-ex'mined de novo.
ENTRAN C£

QUALIFICATIONS

For entrants to the M.B.,B.S. Course, a prior study
for 13 years is recommended. This may be:~
11 years of schooling and 2 years of pre-medical
studies;
or
(b) 12 years of schooling and 1 year of pre-medical
training;
or
(a)

(c)

In states, with 10 years of schooling, three more
years of preparation for vocational training.

There has been near unanimity of opinion that the pre-medical
course should comprise study of Physics, Chemistry, Biology,
Basic Wtiiemti.es in relation to Physics, Language and Social
Sciences, and that for a proper study of so many subjects,
the pre-medical course should be spread over two years. There
is a divergence of opinion, however, on the recommendation
of the Medical Conference that this, two years' course
should be after High School or Higher Secondary Course as the
case may be.
The States who have High School Examination
after 11 years' course are happy with the recommendation. The
States who have Higher Secondary Examination after 12 years'
study contended that the study of the prescribed subjects in
'the final year of the Higher Secondary Examination should be
taken into consideration provided uhat the level of the

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course is maintained high enough to satisfy the requirements
for entry to the M.B.,B.S. Course.

The bulk of the opinion is in favour of conducting pre­
medical courses in Science Colleges affiliated to Universities
except perhaps in Residential Universities like the ones at
Baroda and Varanasi where teachers of the requisite standard
are available in the University Campus, irrespective of the
question whether the course is conducted in Science Colleges
or Medical Colleges.
HIGH

PRIORITY

TO HAVENOTS

In the wake of the popular demand to narrow the gap
between the haves and the havenots of the health services,
it has been the endeavour of Government to identify the
real havenots.
They are the people in distant and dis­
advantaged areas. Doctors in these places need to be
condensate! for the handicaps they have to contend against.
Some ItOO such P.H.Cs have been located. Government have
decided to give a minimum of Rs. 150/- per month as a special
medical service allowance to doctors in charge of these units.

The traditional plan to extend hospital services to
the people is to provide specialist or research institutes
at a few centres in the country, modern hospital complexes
at State headquarters, well equipped district hospitals and
specialist services in referral hospitals at sub-divisional
or taluka places. The underlying assumption is that hospi­
tal services will percolate from cities downwards to rural
folk. In the vortex of limited resources and powerful pul 1s
of the influential and organised urban elements the claims
of the rural folk in distant areas to a minimal of hospital
services within their reasonable reach get compromised and
postponed to a future date. It is difficult to state for
how many Plan periods they will have to wait if the theory
of progressive percolation from top to bottom is to be
adhered to. The situation has been sized up recently by
the Executive Committee of the Central Council of Health.
The Committee has come to the conclusion that special priority
should be given to the provision of minimum hospital
services to areas which have fallen most behind the rest.
?he view has gained ground that within the 1imi tat?nn of re­
sources that are available, the order of priorities needs
■o be reversed - first priority being given to those who

8

are the most disadvantaged.. As a result of deliberations on
these lines, a concrete proposal has been mooted to identify
about 1+00 P.H.Cs in distant and disadvantaged areas which
could be upgraded into miniature hospitals with 25 beds
each. The proposal is being processed with a view to its
early implementation.
ADMISSION

REQUIREMENTS

There is a wide disparity in the basis for admission
to medical colleges in different States. In the majority of
the institutions, the admissions are made purely on the
basis of merit, as revealed by the marks obtained in pre­
univer sity/pre-medical examination.

On the other hand, in some colleges, admission is
based on an entrance test, irrespective of the performance
at the pre-medical examination or in addition to it. Some
institutions subject the candidates to an interview and/or
psvchological test. Consideration is also given to profici­
ency in extra-curricular activities in sports, N.C.C,
mountaineering and for freedom-fighters and their sons and
daughters.
In eight medical colleges in India, admission is on
the basis of capitation fee without much regard to scholastic
achievements. The capitation fee varies from rupees five
thousand to ten thousand in these colleges.
Although, at present admission in the majority of
medical colleges is based on marks obtained by the candidates
at the qualifying Intermediate, Pre-University/pre-Medical
examination, yet recently there has been a tendency to
ignore or under-rate a candidate's performance at the
qualifying examination by introducing the entrance examina­
tion. In other words, the performance at the prescribed
university examination is being compromised by an ad hoc
limited test, the so-called entrance examination. Such an
examination has limited value and has far more disadvantages.
Since such a test would be a written one(and sometimes an
oral one also) and conducted invariably through the medium
of English language, in which the urban elite with better
rommand over language and personal polish would secure an
uncalled for advantage. Besides, it may be the mopt handy
device for giving an unfair advantage to candidates who have

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access to seats of authority and influence, including the
examiners, and perpetuating a distinct disadvantage to
■ candidates hailing from the ordinary run of the society,
particularly from the rural areas.
Minor variations in the percentage of marks secured
by the candidates from various universities are understandable.
These should ordinarily be not so large as to condemn the
assessment of the candidates' merits at the university
examination and to replace it by ad hoc tests. Even if it
is assumed that the variations exceed this limit, we will
have to see whether they can be attributed to artificial
manipulation by the universities concerned. Variations can
be expected in the standard of the old metropolitan
universities and the newer mofussil universities. The
former have a built-in advantage of the best equipment,
talented teachers and long tradition which the lattei’ cannot
mobilize. With such unequal basic conditions of imparting
training, a certain degree of encouragement to the talent
potential coming from the mofussil colleges and universities
should not be frowned upon.
It has been felt that under the prevailing circum­
stances performance at the intermediate science or pre­
university examination should continue to be the yard-stick
for admission to colleges in the States. Where, however,
the facts disclose an obvious manipulation by way of high
marking on the part of any university in a State, it should
be possible to devise a suitable remedy locally to overcome
material disparities in the standards of marking. One such
remedy would be to apply a moderating element by way of a
cross-check of the performance of the same students at the
previous common examination at the Matric level at which all
the students coming from the same State had to appear. This
would provide the basis as to whether and to what extent the
results of the defaulting university should be moderated
vis-a-vis candidates of other universities.

The Conference noted in this connection that as a
result of the evaluation of 15 years' experience of
Hadassah Medical School of the Hebrew University in Israel,
of the three selection criteria, namely Matriculation
Certificate, entrance examination and personal interview,
only the first proved to have a predictive value for success
at all three levels of the course - pre-med icn1, pre-clinical
and clinical.
10

The Medical Education Conference has recommended
that Universities in a State should evolve, as far as possible ,
a common and uniform qualifying examination for entry into
’
medical colleges.
With regard to private medical colleges which charge
capitation fees, the Conference recommended that the criterian
for admission should be the order of merit. They further
favoured the idea of these institutions being taken over by
the Government and recommended to the Central and State
Governments to examine the financial impi i oat.■> ons for this
purpose.

IMBALANCE

BETWEEN

SPECIALISTS

AND

BASIC

DOCTORS

The current trend in medical education is towards
more and more specialisation. This is because of the policy
being followed of giving inducements to persons with post­
graduate qualifications not only in terms of employment,
placement in better stations, but also of a higher social
status in the profession. The ever increasing number of
seats for post-graduate training and grant of stipends further
act as deterrents to medical graduates to enter general
practice after graduation.

While our need is for the "basic doctors',' it is
observed that almost 50$ of about 8,500 doctors turned out
every year go in for post-graduate qualifications in the
country. Another 1000 or so go abroad for higher studies.
This is adjudged to result in a growing imbalance in the
proportion of basic doctors to specialists, for it will not
be long before the deficiencies of teachers in colleges and
of specialists in hospitals will be met from some 5,000
doctors acquiring post-graduate qualifications every year.
Even in more advanced countries, there is a feeling that
this trend towards specialization is overdone in the wrong
direction and a change is indicated in their approach for
correcting this imbalance. The Conference, therefore,
recommended a further study to suggest a balanced supply of
basic doctors and specialists within the limitations of
finance to meet our needs. The task is no doubt difficult
but it is not beyond the resourcefulness of the medical
profession and adnrini strati on to find a suitable answer to
this vexed question.
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DURATION' AND CURRICULUM OF M.B..B.S. COURSE

The Conference endorsed the recommendations of the
Committee that the-duration of the M.B.,B.S. Course should
he
years comprising 18 months for pre-clinical and 36
months for para-clinical and clinical instruction to be
followed by compulsory internship for one year, part of
which should be in the rural surroundings for not.less than
three months under adequate supervision. To improve the
quality nf teaching, the Universities and the faculties
concerned are requested to use the suggested curriculum,
methods of assessment and examination, encouragement of
research and teaching methods given in the Beport. It
also emphasised the teaching of the subject of health
promotion such as growth and development, nutrition, immuni­
sation, health education, family planning, school health
services, routine checkrups and environmental sanitation.
In particular, the teaching of preventive and social medicine
should form an integral part of medical studies for M.B.,B.S.
course and marks obtained in this discipline should be ranked
equal with those of other disciplines for the award of the M.B„B.S.
degree. Some of the general practitioners of experience and
standing should be associated with the education and training
of the undergraduates to make them familiar with the problems
of health in families and community.
EXAMINATIONS

Twenty-five per cent of the total marks allocated for
the University examination have been recommended to be ear­
marked for internal assessment. The Committee has taken
great pains in drawing up model courses, their content and
syllabi as well as al 1ocation of hours in various subjects.
They have been commended to the Universities and faculties
concerned for benefiting therefrom as the guidelines. The
consensus of the method of teaching is to reduce didactic
lectures and to encourage semi nars, group discussions and
clinico-pathological conferences.

MOBILE TRAINING-CUM-SERVI CE HOSPITALS

The scheme of mobile training-cum-service units to be
attached to medical colleges as prepared by the then DirectorGeneral of Health Services - Dr. P.K. Duraiswami - has been
welcomed widely for implementation. The object of these
12

training units with JO beds and adequate accommodation in
tents for staff members is to impart not only the art of medi­
cal care but also broad-based education to tackle problems
of environmental sanitation, nutrition, prevention of
communicable diseases and family planning. Such a scheme is
also required to provide an opportunity to senior members
of the teaching faculty to acquaint themselves with the
field problems. As the scheme is presently sanctioned for
21 medical colleges, similar service facilities can be
provided by senior teachers in their respective rural field
practice areas.

MEDIUM OF

INSTRUCTION

The medium of education in medical colleges has been
recommended to continue for the present to be English.
DOMICILE

RESTRICTIONS

The recommendation of the Committee to reserve
5 per cent of seats in medical colleges for candidates
from other States to begin with and increasing it progressively
to 10 per cent has been accepted with the modification sugges­
ted by the Medical Conference that the reservation of
seats should be on a reciprocal basis. Accordingly,the
details of such reciprocity are being worked out.
RESERVATION OF SEATS

It has been a matter of some satisfaction that the
seats reserved for Scheduled Caste/Tribes in the medical
colleges are being increasingly utilised and there is a
progressive improvement in the performance of these candi­
dates both at the level of qualifying examinations and medical
studies.- Government have endorsed the recommendation of
the committee to continue the present practice of reservation
of seats together with the concession in their eligibility
to these seats if the candidates from Scheduled Castes/
Tribes have up to J per cent marks less than that prescribed
as the minimum requirement for other candidates. Acting
upon the recommendation of the Conference, it has also been
decided to advise the authorities concerned to reserve
5 per cent of seats for admission to candidates who under­
take to serve in rural areas.

13

in rural areas? Do they link up their talent with the
limited services isolated doctors administer in distant
areas? The fate of our efforts at reorienting medical
education will depend a great deal on the answers we give
to questions such as these?" How very true! Example is
better than precept, indeed!
What is then expected of the medical profession?
Two things in the main. Firstly, the medical profession
of tomorrow will bring trained doctors to rural areas and
powerful minds to research. The profession will enlarge
its scope of scientific and technical problems. It should
enlarge in numbers, talent, training, service and leader­
ship. Its success will be measured, indeed, by how well
it responds to the community's demand. Secondly, stock
has been taken of the imbalance in the distribution of
doctors, hospitals, and specialist services among different
parts of the country. A master plan is under preparation
so as to extend the minimum of services everywhere. The
aim is to ensure during the Fourth Plan that there will
hardly be any area, howsoever remote, where health, medical
and family planning services - static or mobile - will not
reach within easy reach from their habitations. This is
a huge task. I would like to take this opportunity to make
a special appeal to the public-spirited medical and para­
medical men and women to enlist their services for at least
a few weeks of their busy time every year in the organisa­
tion of this national programme. There are various ways in
which they can make their contribution, through mobile
hospitals, special camps and many other ways that may appeal
to them to suit local conditions.

community health cell

326, V Main, I Clock
Koramsnge la
Bangaloi 6-560034
India

Position: 385 (9 views)