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Qa.
C H.c. - C.M.A.I. - C.M.A.T.
PROJECT
1990-92)
^i£
""TV MCA! TH
r*E| |
CHC / MEP /
Research Project
Strategies for Social Relevance and
Community Orientation in Medical
Education : Building on the Indian
Experience
STEP
BY
STEP
Community Health Cell, Bangalore
*
June
1992
Sponsored by : Christian Medical Association of India (CMAI),
Catholic Hospital Association of India (CHAI), Christian
Medical College, Ludhiana (CMC-L).
*Society for Community Health Awareness, Research and Action,
No. 326, V Main, I Block, Koramangala, Bangalore - 560 034.
i
The
challenge of reorienting Medical Education to
the
health
needs of our people in the
meet
socio
diverse
cultural-political-economic realities of our country has
been an area of interest
the
of both the researchers
of their graduation
time
St.John's
from
from
Medical
College, Bangalore in 1972 and 1978 respectively.
interest
was
experiences
Andhra
This
particularly, stimulated by
internship
<
in a Bangladesh refugee camp (1971), and a
cyclone
Disaster
Relief
(1977).
Camp
experience
of the practice of primary medical
conditions
of mass poverty and
situation,
led
to
a
relevance
of
the
large,
process
The
care
in
disaster-linked
health
of
on
reflection
the
teaching
high-technology,
hospital focus of medical education in preparing doctors
for
the challenges of community health.
led
to various reflections, and initiatives related
This
interest
medical education over the past two decades, which
been
brought
articles
experience
"Medical
Education
CHC
has
together in this
that
led
the
It was
researchers
Education Project"
entitled
to
this
of
varied
evolve
the
Strategies
far.
Building an the Indian Experience, which the
facilitated
since
April
1990.
An edited compilation of the key articles, which
the
have
anthology
separate
and reports (See Table).
to
formed
background to the project, was therefore seen as
a
logical first step as well as a component of the project
I
I
- STEP BY STEP -
Towards An Appropriate Medical Education
I
I
I
I
I
I
I
I
I
I
I
I
I
I
The CHC/CMAI/CHAI/CMC-L Project on "Strategies
for Social Relevance and Community Orientation
in Medical Education - Building on the Indian
Experience'
was based on a long involvement
of the primary researchers in exploring how
medical education could be made more relevant
to the needs of society. These included
many
initiatives before the formation of
CMC,
followed by some during CHC's formative years.
This report therefore brings together the key
initiatives/reflections of the
researchers
which
preceded the study and helped to give
the project greater focus.
CONTENT KLSX
INTRODUCTION
A. TOWARDS AN APPROPRIATE MEDICAL EDUCATION - STEP BY STEP
B. REFLECTIONS OF AN INTERN (1972)
C. TRAINING DOCTORS FOR COMMUNITY HEALTH SERVICES (1973)
D. LESSONS FROM A YEAR OF TRAVEL AND REFLECTION (1982)
E. MOVING BEYOND THE TEACHING HOSPITAL (1988)
F. MEDICAL EDUCATION - TOWARDS GREATER SOCIAL RELEVANCE (1989)
G. AN ALTERNATIVE VISION OF EDUCATION FOR
CARE (1990)
DECENTRALISED
HEALTH
A££EXD±C.EJS
I
FEEDBACK FROM PIONEERS OF A RURAL BOND SCHEME (198/1)
II
MEMORANDUM ON A HEALTH UNIVERSITY TO GOVERNMENT OF KARNATAKA
(1988 )
III
"PROS' AND "CONS' FOR AN ALTERNATIVE MEDICAL COLLEGE (1989)
IV
MFC ANTHOLOGY HANDOUT.
]
I
I
I
■
COMMUNITY HEALTH CELL.
Society For Community Health Awareness, Research And Action,
326, V Main, I Block,
Koramangala,
BANGALORE 560 034.
1
!
1
I
!
A. TOWARDS AM APPROPRIATE MEDICAL EDUCATION
Step hiJ. S-LfiP.
1. In 1971 RN worked in a Bangladesh refusee camp in Neelganj,
near Calcutta, for three months as part of the public health
postins
in
his compulsory rotating
internship.
This
experience began a process of serious reflection on medical
education which led to a student/intern 's reflection on Makins
Medical Education nel.ey.ant. Xe Xlie. needs aX society - a paper
presented at the first students seminar organised by the
Indian Association for the Advancement of Medical Education at
its annual. Conference at the Armed Forces Medical College,
The paper made a plea for
Pune in February 1972 (Article B).
the widening of a medical student's horizon from a severely
clinical-patient
oriented outlook to a
wider
socially
conscious - community outlook.
The paper was published in the
Indian Journal of Medical Education as well as in the Indian
Journal of Preventive and Social Medicine. It was later quoted
by the Parks textbook of Preventive and Social Medicine ( now
Community Medicine) in the chapter on 'Concepts in Community
Health' in the section on 'Barriers to Health Services'.
"Shortcomings Xa medical
The system of
medical education may itself be a barrier to health
services if the medical education is not oriented
to
the needs of the community.
This is a subject of great
criticism in India .
*
Tha
shortcomings of
medical
education are stated as follows:
a) It is not structured to meet the
community.
health needs of the
b) It is not community oriented.
c) because it is hospital oriented, too great emphasis
is laid on specialisation.
Consequently
the young doctor is not
emotionally
prepared to face his new role in the community".
2. In June 1973■
RN submitted a dissertation to the London
University for the Diploma in Tropical Public Health on the
theme of Trends In. Undergraduate Medical Educe lion 1 n Indi a j_
TralnIng doctors fPF Community Health Services■
This dissertation was an overview of 25 years of post
independence development in Medical Education in India.
It
covered areas such as the History of medical education; growth
and development of medical education since independence;
the
challenge of medical care in rural India;
reorientation of
Medical Education for Community Health Services;
incentives
for Rural work; Medical Education and migration of medical
manpower and a discussion on alternative approaches to reform.
The
dissertation was in response to a proposal
being
considered by the Government of India (at that time),
to
evolve a course for doctors that was shorter and less
expensive than the existing one.
2.
3
The dissertation outlined a few principles which could be
applied in the planning of a proposed 3 year diploma course.
It also made a concerted plea for a continuing process of
reorientation of the ongoing M.B.B.S.
course (see article C)
which included;
1) University involvement in health care;
11) Improvement of standards of teaching and teachers;
ill) Documentation of local knowledge and
development of local technology;
needs
iv) Appreciation of economy and effective
of available services §md resources;
utlllization
and
v) Involvement of general practitioners;
vi) Need for evaluation of introduced changes; and
vii) Motivation of the medical profession.
3. From
1973-1983,
both the primary researchers
had
the
opportunity to participate in a process of reorientation of
Medical Education at St.John's Medical College,
Bangalore
which included primarily the development of many rural and
urban field practice areas and many efforts to move training
beyond the teaching hospital.
Two initiatives Rural
Orientation Camps and Rural Community Health Clinic Experience
for interns were particularly significant and were reported in
the Asian Community Health Action Network newsletter .
(See
Article E).
U.
In 1977.
RN had the opportunity to study and reconstruct
(through documentation review, field visits and Interactive
interviews),
the Kotta.vam Experiment as a project during his
postgraduate studies at the All India Institute of Medical
Sciences,
New Delhi.
This experiment,
relatively unknown,
conducted by Prof. Jacob Chandy, Neuro Surgeon and ex Dean of
Christian Medical College, Vellore, was a post retirement
effort aimed at operationalising a project which he was unable
to undertake earlier while working in a 'medical college
situation'
- under the framework of the MCI recommendations.
The experiment attempted to train a community oriented health
professional
in what was India's only
experiment,
in
integrated, community based training.
5. In 1982, both the researchers
'dropped out' of faculty
positions in the medical college and spent a year travelling
to many parts of the country to visit doctors and health
workers
trained by the college and to experience
the
challenges and problems they were facing in 'health action'
at the grassroots.
This year of travel and reflection was a
• very intense 'personal' and 'dialectic' experience which was
documented in a reflection note that was circulated to
colleagues and peers in 1983/8U (See Article D).
4.
6.
In October- 1933. the primary researchers moved beyond their
medical college jobs to a study-refleetion-action experimental
project
(Community Health Cell) with voluntary
agencies
involved in Community Health in South India,
particularly
Karnataka.
While medical education was not the main focus of this
experitnentai project there were many occasions and stimulus
for involvement in further reflections on reorientation of
medical education to meet the challenges of community health
in India.
7.
i) In October 1983,
years
(RN) wrote a review article entitled "150
Me.dica.l Education: Rhe toric and Relevance" as a
background paper for the medico friend circle annual
meeting in Calcutta on Medical Education .
This was
published in the medico friend
circle bulletin
in
January-February 1984. (Appendix IV)
7. ii) As further background to this meeting, a compilation of
the key recommendations of Medical Education by four
expert committees appointed by the Government of India
were also made.
These included the Bhore Committee
(1946), the Patel Report (1970), the Srivastava Committee
(1975) and the Health for All - an alternative strategy
report of the ICSSR/ICMR study group (1981).
This was
distributed to all those interested in the compilation, on
reques t.
8.
In December 1983.
as part of
the first visit
of Dr.
Zafarullah Chowdhury (of Gonoshasthya Kendra Project
of
Bangladesh) to Bangalore,
an adhoc meeting on
'Medical
Education' was organised at St.John's Medical College.
At
this meeting Dr.Zafaru1lah had an opportunity to share some of
the early thinking of the 'alternative medical school'
being
planned by a group in and for Bangladesh.
9.
In January 1934,
the Annual Meeting of
circle
considered various aspects of
reforms, particularly:
a) Content and structure of
para-clinical teaching.
the medico friend
Medical
Education
pre-clinical,
clinical
and
b) Content and structure of community medicine teaching and
c) Methodology in present system of education.
10.In May 1934, CHC facilitated a workshop organised Jointly by
St.John's Medical College and Catholic Hospital Association of
India
for the first twenty pioneers of a Rural
Bond
(Placement) Scheme organised by the college since 1980.
The
Workshop gave an opportunity to the participants to reflect
on:
a) Medical Education, and
b) Challenges and problems of peripheral
pract1ce.
I
hospital
5
The report and recommendations on medical education (See
Appendix X) was submitted by a small team (nominated by the
workshop participants) to the staff council of the medical
college to coneidei’ and reflect upon, with a view to introduce
changes in the curriculum and methodology of teaching in that
college, so that the rural placement scheme would be seen more
as
a
'challenging opportunity' rather than.
Just
an
obligation.
ii
In
the
years 198/1-86,
the CHC
also
shoulderd
the
responsiblity of managing the organisational responsiblities
of the medico-friend circle,including the convenorship and the
editing and publishing of its monthly bulletin.
During these
years.
the proposition to work towards an mfc statement on
medical education as well as an anthology on that theme was
mooted and accepted as an important and meaningful initiative.
Articles and group reports were edited and compiled by an
editorial collective.
In 1988/89, taking the opportunity of a
delay in publishing the anthology, two additional articles
were added by CHC to the original collection, to make it more
comprehensive and to keep the readers better informed about
the evolving situation of medical education reform
and
innovation in the country.
a) An article highlighting 'Recent initiatives towards the
Alternative' brought together information about
the
National Health and Educational Policies; the JNU plea
for a new public health;
the ROME experiment;
the
Kottayam experiment;
the Network of Community Oriented
Health Science Institutions; the abortive attempts at
an alternative track - 1988; the Consortium of medical
colleges
on Inquiry Driven Strategies;
the
MiraJ
Manifesto;
the Health University Development;
the
National Teacher Training Centre;
the Epidemiological
Networks;
the Edinburgh Declaration of 1988;
and the
perspective plan for the Scientific Advisory Committee.
While reviewing all these positive developments,
the
paper also highlighted the disturbing developments in
health care and medical education including, 'capitation
fees’ colleges,
privatization;
diagnostic technology
glorification,
the unsolved private practice problem
and so on.
b) The second addition by CHC, probably adding greater
significance to mfc's efforts, was the development of a
compilation on the lines of the Medical Council of India
Curriculum - 1982, of an alternative framework of a
curriculum
entitled
'Anthology
of
Ideas'.
This
compilation evolved from various extracts of articles
and group discussions in the Anthology.
The mfc Anthology was published in January 1991 and included
both these articles as well as the 150 year review article
mentioned earlier (Appendix IV)
In 1988 CHC initiated an informal network of community health
action initiators in Karnataka, primarily Bangalore based,
called the CH-Network.
In one of the regular meetings of the
network, many of the participants felt that we should make a
6.
representation through a memorandum for the consideration of
various relevant options and alternatives by the newly
constituted Committee for the University of Health Sciences
in Karnataka set up by the Government of Karnataka.(See
Appendix II)
13. In October 1988, CHC facilitated the first Trainers Dialogue
organised by Voluntary Health Association of India at the
National
Institute of Mental Health
and
Neurological
Sciences,
Bangalore. Twently two participants representing
various community health training groups in the voluntary
sector of the country gathered for the first time to share
experiences and discuss issues of common interest and concern
(Report available from VHAI, New Delhi on request.)
Itt. As part of a process for lobbying for change the
mfc
'Anthology of ideas’ was circulated by us in CHC,
to the
Deans/Directors of a few key medical colleges as well as a
few other faculty and resource persons.
A number of
interesting
interactions
and
some
dialogue
through
correspondence took place through this process.
i) We
had
a
series of
discussions
with
Prof.
P.Zachariah,of CMC - Vellore who evolved the Mirai
manifesto of a ’Community based medical college’
through a sabattical interaction with the faculty of
MiraJ Medical Centre and extensive discussions and
visits with resource persons all over the country.
CHC sent a formal response to three questions put by
him, which are included in Appendix III,
To explore
the diversity of options we looked at the 'positive'
and 'negative' aspects of all the questions.
ii) CMC-Ludhiana had started many initiatives towards an
experimental parallel curriculum and in its final
application
for such a curriculum in 1990,
it
submitted the mfc Anthology of Ideas as part of the
alternate experiment. CHC initiated a dialogue with
CMC-Ludhiana,
including a visit to meet the faculty
and had many discussions with Dr.Alex Zachariah,
Principal and key catalyst of the initiatives.
15- In 1989 the Christian Medical Association of India (CMAI)
facilitated a Network of four Christian medical colleges
(CMC-Vellore,
CMC-Ludhiana, St.John's Medical College
Bangalore and the Mirai Medical Centre).
At the first
meeting of this network in August 1989, RN from CHC was
invited to give the keynote address which was entitled
'Towards Greater Social Relevance' (See Article F) .
The
paper later published in the CMAI journal gave a historical
overview of the medical education reform process in India,
a
summary of the key developments of relevance in the present
and outlined a series of challenges for the evolving network
in the future.
16. In 1990,
1991 and 1992, CHC participated in the ongoing
deliberations of the evolving network of Christian Medical
Colleges - which discussed a wide range of issues including
ethics both institutional and teaching in medical curricula,
formation of teachers, response to the challenge of AIDS,
value orientation and so on.
7
17. In September 1990,
CHC participated in the planning and
organisation of a National workshop on the theme
'Towards
a Decentralised Health Care: A fresh look at the National
Health Policy' organised by the National Institute
of
Advanced Studies.
Bangalore.
The two areas in which CHC
presented papers during the wide-range of discussions were
'An alternative vision of Education for Decentralised Health
Care’
(See Article G) as well as Research Priorities for
Decentralised Health Care.
18. CHC has been planning and compiling on invitation, one issue
every year of Health Action (the monthly publication from
Health Accessories for All Trust, Secunderabad).
In 1988, it
was on Community Health, in 1939 on Rational Drug Use and in
1990 People's Participation in Health Care.
In June 1991, we put together a special issue - Medical
Education where
it JLaad. 2 which included the key cover
story entitled Training
Doctors for India and articles on
History of Medical Education in India;
the challenges of
continuing education; Medical Ethics, medical malpractices
and patients' rights, the Kottayam experiment; the experiment
in 'Samaritan Medicine';
the Edinburgh Declaration;
and
reflections by students and interns of various community
based alternative programmes.
The special issue was mailed to all the health professional
training institutions in the country, viz.,
allopathic,
ayurvedic, homeopathy, and also to training institutes for
nurses, pharmacists, physiotherapists, dentists and vets.
19- In
April
1990. CHC initiated the
project
entitled
'Strategies
for
Social
Relevance
and
Community
Orientation of Medical Education Building on the Indian
Experience'. This
project was sponsored by CMAI (New
Delhi) and CHAI (Secunderabad) and supported by the Network
of Christian Medical Colleges.
20. Tn. October 1991 the CHC team (now the functional unit of the
newly registered and autonomous Society for Community Health
Awareness,
Research and Action) facilitated the
second
meeting of Community Health and Development Trainers in the
Country to reflect on the issues arising out of the recently
circulated Draft National Educational Policy of
Health
Sciences and to evolve a 'Statement of shared concern and
evolving collectivity'. This statement and proceedings were
circulated to all the participants concerned as well as its
key policy makers in the country.
The CHC Medical Education Project sought to weave into its
report
many of the ideas and outcomes of
all
these
initiatives described earlier.
(See Table I).
The
project
ended in March 1992■ A Faculty
Resource Manual which will ,be
one of the main outputs of this project, is scheduled to be
completed and released in 1992. The project got inspiration and
perspective derived deeply from all these earlier steps.
1
SUMMARY
:
TABLE I
TOWARDS AN APPROPRIATE MEDICAL EDUCATION
- Step by Step
YEAR
INITIATIVE
PUBLICATION/REPORT
|
1972
Refugee Camp Experience
Making Medical Education
Relevant to the needs of Society
- Interns reflections (B)
|
1973
DTPH Dissertaion
Training Doctors for
Community Health Services
(Trends in Undergraduate
Medical Education in India)(C)
1973-83
Community Orientation
of Medical Education
- SJMC, Bangalore
Moving beyond the Teaching
Hospital (E)
1977
MD - Term Project
The Kottayam Experiment:
Training programme for
Community Nurses/Health
Supervisors
I
1982
1
1
Year of Travel and
Reflections with
Community Health
Action initiators
at Grass Roots
Notes on a year of Travel and
Reflection in the context of
Social orientation of Medical
College education (D)
i98U
mfc Annual Meeting on
Medical Education Calcutta
Background paper (150 years
of Medical Education:
Rhetoric & Relevance)
Workshop for Rural
Bond Scheme Pioneers
Report of Workshop for Rural
Bond Scheme Pioneers(Appendix I)
CHC Network - Sub
Committee on Medical
Education
Memorandum on Health
University (Karnataka
Government) (Appendix II)
1989
Network of Christian
Medical Colleges
Keynote
Address: Medical
Education: Towards
greater social relevance (F)
1990-91
mfc Anthology Medical Education
Re-Examined
3 Articles in Anthology
including Anthology of
Ideas (Alternative
Framework) (Appendix IV)
1990
NIAS Workshop on
Decentralised Health
Care & National
Health Policy
An Alternative Vision of
Education for Decentralised
Health Care. (G)
1991
Health Action(Special
issue)
Training of Doctors for
India
|
1
| .
■
|
1988
■
•
1
1
1
I1
1
.... - ...
........
...
8.
9
B.
REFLECTIONS OF AN INTERN (1972)
.INTRODUCTION
The history of Medical Education in India, reaching down over the
decades - for over 100 years, has seen no major chances in its
pattern, structure or adaption to the changing needs of Indian
Society.
The health needs of India are varied.
Side by side we
have existing the bullock-cart ace where primitive practices of
sanitation and hygiene result in a mortality of over 30% in the
rural areas;
and we have the Jet ace in our bic cities where
cancer, hypertension.
Diabetes, Mental illnesses and other so
called diseases of civilization are taking & heavy toll.
In
addition even after over two decades of Independence and National
planning, the problem of uneven distribution of Medical personnel
i.e. 20% of Doctors in areas where 80% of the population resides,
still continues.
This is irrespective of the increase in number
of medical colleges from 25 in 19U.7 to 97 in 1971 and the annual
admissions from 2000 to 12000.
Since our Medical Colleces
continue to be located in the urban areas, the needs of the rural
populaton have been sadly neglected and in addition the concept
of community health even in our urban areas has not been
adequately stressed by these colleces.
Therefore the greatest
need in India today is
1.
To make Medical Education more community oriented.
2.
To reorient clinical training to
doctors for work in Rural areas.
prepare
our
young
5ASIC DOCTOR
The present system of Medical Education serves admirably to train
our young graduates for work in our large city hospitals
modelled on the British and American pattern and not in our rural
and semi-rural community centres. The needs in a rural area are
very different from those in an urban society.
"In the urban
areas one can accept the responsibility for a limited group of
people knowing well that others can seek and obtain equivalent
advice and care elsewhere but in rural areas a doctor must accept
responsibility for a large number of people often quite beyond
the possibilty of his own personal management acknowledging that
if he declines this responsibility he deprives them of all
sources of medical help".
In order to work in a rural area
therefore a doctor must be what the Government of India defines
as a "Basic Doctor" - i.e :
"one who is well conversant with day
to day problems of urban and rural communities and is able to
play an effective role in the curative as well as preventive and
promotive aspects of regional and. national health problem".
SHORTCOMINGS IK TEE PRESENT SYSTEM
The
present
system
makes
the
young
medical
graduate
'professionally incompetent’ and 'emotionally unprepared’ to face
his
new role in the community because of the
following
Si'ioP'tcoiijj.ngs:
10.
1. EdUCSt let. E£. not Community Orientec :
Medical Education in India is very hospital oriented and not
community oriented.
The doctor does not learn to treat his
patient within the context of his life in society but on the
basis of brief encounters in the wards.
He loses sight of the
fact that the stress and strain of everyday life affects the
patient both in health and disease and if this is not taken
into consideration the treatment becomes one sided.
2. Academic Environment g>E Institutions
The environment in nearly all the teaching institutions is
highly academic where each person endeavours to work in as
narrow a field as possible.
This stress on specialization
leads to the fragmentation of a patient, snaking medicine more
organcentred.
The student therefore prefers to specialise
rather than take up general practice.
3- stress gn Curative- Medicine ■
Too much stress is laid in our teaching hospitals on curative
medicine and little or no stress on the preventive and social
aspects. A student studies these aspects through a course of
didactic lectures but no attempt is made to make these
concepts a practical reality with reference to the cases in
the ward.
li. Foreign
in Medical Educetd-QD:
The textbooks we study are all written by foreign authors
whose experience is based on cases and facilities present in
their hospitals.
The student thus develops a foreign bias and
is not able to reorient his knowledge to suit the special
needs in our rural areas or even in our smaller urban
communities .
COMMUNITY ORIENTED MEDICAL EDUCATION
To make our system relevant to the needs of our society certain
changes have to be introduced in our present patterns of
training.
In this paper the changes are suggested in order, from
the pre-professional year to the period of internship. Many of
them have been suggested in other papers on this subject in the
last few years and repetition is unavoidable.
All
these
suggestions have been discussed with students and all of them
have been found to be acceptable to them.
a) Pre-Professional Student Counselling:
All high school and pre-university students planning to
up medicine as a profession must be counselled :-
take
i) To make them aware of their responsi1ibity to society.
ii) To prepare them to meet the special demands of the long
medical course.
This measure will prevent wastage of
potential medical personnel due to chronic failures
caused by disinterest and emotional inadequacy.
Also
for girls who do not plan to pursue their profession
efter nsrr.i&JA this counselling would help them to
choose other- less demanding professions.
11
Pre-Professional Course :
The present pre-professional course is to a lapse extent an
unnecessary repetition of the higher secondary or preuniversity
course.
All the subjects taught are not adequately medically
oriented :
i) In
Botany
or Zoology the stress
should
be
on
understanding the basic principles of human anatomy and
physiology by a study of similar structure and function
in plants and animals.
>
ii) In Physics and Chemistry - various aspects of
Biophysics and Biochemistry should be stressed.
so-called
iii) The student should be prepared for his role in society
through
lectures rin certain aspects of
sociology)
anthropology,
elements of economics,
statistics
and
biomathematics even at this stage.
1. Anatomy and Physiology form the basis of our medical
education and the content of these courses cannot be
radically altered except that the teaching should be less
cadaver-oriented and more clinically oriented.
The student
must be exposed to clinical material to help him understand
better the normal anatomy and physiology of an individual
and the changes in them which constitute disease.
2. The introduction of Preventive & Social Medicine at this
Stage is very welcome.
The student must be taught about
Nutrition, Environmental, Industrial and Personal Hygiene,
Population Dynamics and National Health problems
and
programmes.
A systematic course in the social sciences
i.e.
:
in Sociology and Psychology at this period of
training will make the student aware of certain duties
towards the community which are overlooked during the
hospital training.
Clinical Course :
It is during this period of training that medical students can
be made most community and 'rural'
conscious.
Though the
hospital is the centre of his training an attempt should be
made with the help of a well organised community health
department to shift the emphasis of training and research from
the hospital to the whole community in which the hospital
resides.
This can be done by :
1. Clinical bed-side teaching must take into account the
preventive and social aspects of diseases encountered in
the wards and the student should be encouraged to study
these aspects in each case. e.g. : In a case of T.B.
i) a follow up of the patients contacts must be made,
ii) at the time of discharge the patient and his
family must be educated on the health measures to
be taken to prevent spread of the disease.
12
iii) a study of the eocio economic circumstances in
which the patient developed T.B. should be made.
This
will help students to
understand
and
appreciate all aspects of a disease and its
treatment.
2. Throuthout the course in addition to the ward training the
students,
in batches must be made responsible for the
primary health of organised groups in society like school
and college students, children in orphanages,
inmates of
destitute homes, rehabilitation centres, prisons and in the
bit cities even of localised slums.
The stress should be
on primary health care and mass screening.
After his first
clinical year the student will be in a position to take
keen interest in such activities.
One of the criticisms of
hospital training is that the students are not given enough
responsibility in the treatment of the patients.
The above
scheme would help them to shoulder this responsibilty and
make them more conscious of their usefulness in society.
Recently the Bangladesh Refugee problem gave many of our
interns and students an opportunity to voluntarily accept
the responsibility of a large number of people for a
certain time and this has been a very rewarding experience.
3- A Rural orientation is necessary in order to prepare a
student for work with rural conditions,
culture
and
traditions and the psychology of villagers.
This can be
done by :i)
a study of an Indian Textbook which should be
prepared on the lines of the book "Medical care in
Developing countries - a symposium from Makerere Nairobi which is based on African rural conditions.
ii)
Practical training in rural areas for upto 6 months
during the clinical years and 3-6 months during the
period of internship.
The Preventive & Social Medicine Department which would
also be a Public Health or community health department has
a very important role during the clinical years.
In
addition to the coordinated activities suggested above
students should be helped to conduct surveys and studies in
the field-work areas in nutrition, infant care, maternal
welfare and in diseases like TB, Cancer, Malnutrition and
Diabetes.
The students could also be posted in this
department for 1-2 months for participating in the above
schemes.
e) Internship :
Finally
medical
rr
senior
it is during the period of internship that the young
graduate will be able to determine how well oriented
work
the rural o- P G ex S
if he is posted in a
health centre for 3-6 months.
In the company of a
doctor and his colleagues be will get a first hand
13
impression of the type of work in Rural Medical Centres, which
will give him a background for possible village work after
Internship.
Each Medical college could take over a few
primary health centres or start its own rural health centres
where such training could be imparted.
This programme could
be planned out with the Government District Health Officer so
as to prevent too much overlapping in the health care of
particular villages.
In this connection the government scheme
of supplying 50 bedded mobile hospitals to medical colleges to
provide opportunity for rural work is very welcome.
f) Postgraduation :
According to latest estimates at least '50% of
Medical
graduates go in for higher studies either in the country or
abroad.
One of the main reasons is that young doctors who
qualify have to compete with their seniors who are already
well established in the urban areas.
Therefore to enter this
highly competitive field they feel the need of a postgraduate
degree of specialization.
If at this stage however the
government offers certain incentive like "good living and
working
conditions,
vehicle for field work,
visits
to
specialised institutions in the country and abroad
and
opportunities for professional advancement by way of admission
to postgraduate courses after completion of 2-3 years in rural
areas",
I am sure with the added background of rural
orientation during the medical course the majority
of our
young doctors will opt for the rural areas.
In conclusion it can be said that the crying need of the moment
in the field of medical education is to widen the horizon of the
student from a severly clinical-patient oriented outlook to a
wider,
socially conscious community outlook and a
student
symposium such as this is a very constructive step in this
direction.
BIBLIOGRAPHY
1. Reorientation of Medical Educaion for
Community
Health
Services by : B.P. Patel - Secretary Minister of Health &
family PLanning.
2. Indian Journal of Medical Education - April and May 1970.
Volume IX - ll & 5. Conference issue.
The Role of teaching
hospitals.
Non-teaching hospitals, health centres and other
health services in Medical education
3- Indian
issue.
Journal
of Medical Education - Volume
IX
Oct.
i) Medical Education for India - Dr. K.K.Shah
ii) Utilization of Health Services for
medical education - Dr. B.G.Prasad
iii) Problems of Medical Education
undergraduate
Dr. B.Mukhopadhyaya
1970
1k
L. Medical Care in Developing Countries - A symposium
Makerere. Edited by Maurice King (Oxford Publication)
5. A review of the nature and uses of examinations
Education - WHO Public Health Paper No. 36.
in
from
Medical
6. Preparation of the Physician for General practice - WHO Public
Health.
Paper No 20
7. Proceedings of the I World Conference on Medical
London - 1953 (oxford University Press 195^)
Education
S. Bharat Medical Journal - Volume 3 - No. 2, April 1971.
i) Teaching
Preventive
and
Social
Medicine
to
undergraduates - Dr. B. G. Prasad and Dr. J . K. Bhatnagarii) Changing Horizons in Medical Education - B.Mahadevan
iii) Research and Service aspects of Teaching Preventive
& Social Medicine.
9. Background
papers of U.G.C. Institute
Sciences in Medical Colleges.
for
teaching
Social
i) Changing needs of Medical Education - .N.Rao
ii) Social Science content in Undergraduate teaching of
Community Health - D.Banerjee.
iii) Rural Health Problems and preparation of physician H.S.Takulia.
iv) A case for integration of social sciences and medicine
and medicine and medicare - Hari Vaishnava.
v) Doctors as a Modernising elite - T.N.Madan.
i Source:
i) Indian Journal of Medical Education,
Vol.
II, Nos. 2 & 3 (Apr. - Sept. )
1972 P 1-41.
ii) Indian
Journal of Preventive
&
Social Medicine, Vol. L, June 1973.
P 69 - 71
15
C.
TRAINING Q.QCTQRS RQR COMMUNITY HEALTH SERVICES (1973)
Medical education in India is at the crossroads. A time has cone
for a radical appraisal of the entire system and an assessment
whether we are progresing in the right direction.
The post-independence burst of energy led to a remarkable growth
in medical education which was, however, quantitative rather than
qualitative.
The aims and objectives were exalted from the very
beginning,
and the translation into performance would have been
possible, only if all the medical educators and students had been
paragons of dedication . (TAYLOR, 1970). 5y the end of the first
decade, it was discovered that the doctor in India would have to
be very community-oriented and that the hospital oriented system
with a dichotomy of preventive and curative services,
which we
had inherited, would never produce the type of 'basic doctor’ we
required.
A reorientation of the system was,
therefore,
necessary.
Like the medical profession all over the world we, in India, were
still 'traditionalists’
and resistant to change,
and so the
measures taken towards this reorientation were half-hearted and
indicate only a partial solution.
Volumes of papers and hundreds
of speeches were made on the health needs of the village
communities,
and the need based changes required in the medical
curriculum but "imitation of western patterns and anxiety to
reach standards acceptable by the western institutions resulted
in a blurring of vision to create and develop an educational
pattern that would fulfil the expectations and needs of the rural
societies" (RAO, 1966)
Most universities decided that adding a course in preventive and
social medicine and providing time in rural health centres would
be adequate measures to give students the required community
health orientation.
Many departments of preventive and social
medicine,
however, made pioneering attempts in evolving new
concepts of community health training,
(refer Table I) which
helped to improve the status of the subject, in the eyes of the
students and staff.
The clinical departments were slow to
respond and many continued to give the students a narrow hospital
orientation,
in the mistaken belief that the community health
orientation of the student was the sole responsiblity of the
preventive
and social medicine department.
The specialists
continued to load the student with unnecessary details of their
specialities,
patterns of research followed the fashionable and
sophisticated pathways of medical research in developed countries
and, therefore, the medical colleges continued to produce doctors
who preferred the organised and protective health systems of the
hospitals,
rather than the challenging task of rural service.
Planners and educators appeared surprised at the reluctance of
doctors to man the health services in the rural area, and it took
them quite a time to realise that the fault was in the
educational system, that neither trained nor prepared them for
the task and often, actually, interfered with the development of
self reliance and confidence required to meet the challenge of
rural health centre service in India.
i6
~t would interest educators in India to know that the protected
development of the undergraduate has gone so far in the British
system that the TODD report (1963) made the following interesting
observat ion.
"Every doctor who wishes to exercise a substantial
measure of independent clinical judgement will
be
required to have a substantial postgraduate professional
training, and the aim of the undergraduate course should
be to produce not a finished doctor,
but a broadly
educated man who can become a doctor by
further '
training".
It is moot point, therefore, to consider that having adopted the
British system, with subsequent minor alterations, whether we could
afford to produce such 'broadly educated men’ who could serve the
community only after years of further training - for this is the
observed result of our present system.
Another
interesting
questions that needs to be answered is whether we should reduce the
largely futile dependence on expensive over-trained physicians, and
experiment with new grades of medical workers.
In its approach to
the Fifth five-year plan, the Planning Commission (1972) states
that
"The emphasis in rural health will have to be on
prevention, family planning, nutrition and detection of
early morbidity with adequate arrangements for referral
of serious cases to the district hospital.
Such a
multi-tier system cannot be built on a national scale on
the basis of the present expensive system of prolonged
medical education.
In order to provide an adequate
number of doctors for the Fifth plan programme, and as
an advance preparation for a more intensive coverage
later, it would be necessary to consider the revival of
the 3-year medical diploma.
Indigenous systems of
medicine will also have to be utilized for the purpose."
The Government has, therefore, clearly indicated that the training
of a new type of doctor through a shorter course is imminent in
India.
Though the details of such a course are outside the scope
of this dissertation,
it would be worthwhile to discuss a few
principles that could be applied in planning such a course:
1.
3, Sc , r. -Fural Medicine :
The most important principle is that the proposed 3
year diploma course should not be a revival of the
earlier licentiate course which we abolished at the time
of Independence.
Since then the medical profession in
India has been highly suspicious of attempts to revive
condensed M.B.3.S.
courses and training of what are
often known as 'near doctors' or 'subprofessionals'.
The object of the course should be to produce a doctor
who is so specifically trained for rural health centre
service that he becomes more qualified for that job than
the average graduate M.B.3.S..
In fact, the 3 - year
course should lead to a Bachelor's degree in rural
medicine, and not be underrated by calling it a diploma,
and making it appear to be a lower qualification.
17.
2.
Principles
Training :
The traininj of the new cadre of doctors should
the principles suggested by ROSA (1964):
follow
i) Approach based on local problems.
ii) Maximum use of community self help.
iii)Training muat Ha i_a
environment where his future
■lob Wili Ha (Rural health centre) .
iv) 3road perspective of rural problems.
v)
Efficiency in mass methods of treatment, vaccination
and so on.
vi) Appreciation of economics.
vii)
Strong basis in maternal and child health
principles and practice of health education.
and
viii) Training should be very practical and realistic.
In
fact ideally it should be two-thirds practical,
and
one-third theory.
3-
Regional Planning :
The training of this new cadre should be regionalised
and specifically oriented to meet the needs of the
peripheral
health services in "■ each state.
Close
cooperation between the medical colleges of the state
and the government health services especially
the
primary health centres and district hospitals should be
encouraged.
4.
Critically evaluate 'Indian’ experience :
The findings of the Rural Health project at Narangwal
(TAKULIA et al, 1967) and the long experiences of many
departments of preventive and social medicine in the
country,
in the organisation and problems and training
in a rural health centre setting should be closely
studied before evolving the new diploma course.
5.
liSjam. fgQm 'non-Indian' Experience :
Such locally-oriented cadres of medical workers have
been trained all over the world, and the experience of
educators of feldhsers in U.S.S.R. peasant doctors in
China,
physcian assistants in U.S.A.
(DUKE UNIVERSITY
SCHEME) and medical assistants or Health Officers in
Fiji, Tanzania, Malawi, Sudan,'Uganda, Ethiopia,
Kenya
and Nigeria should be consulted in the planning of the
new course.
These are described in FENDALL (1972) GISH
(ed. 1971). KING (1966) BRYANT (1969) TITMUSS (1964) AND
WADDY (1963).
I
18
5.
Selection Procedures :
Selection
of
carefully done.
students
for
this
course
should
be
Stress should be on a rural background, a command of the
local language,
a familiarity with the people and a
commitment to return to the rural area for work.
Stipends should be made available to these students
during their training, and on completion they must jet
Jobs as close as possible to the areas from which they
were selected.
The village panchayats could also help
in the selection of the right type of students.
7.
Course ObiectIves :
The content of the course should be practical and
The training must prepare the rural doctor for
vital functions (FENDALL, 1972):
realistic.
the three
i) To act in a screening capacity and refer to more highly
trained professionals ,
patients in need of greater
diagnostic acumen and skills.
ii) To treat visible sickness and cater to simple
requirements
such
as routine
midwifery,
sanitation, water and housing Improvement.
health
simple
iii) To render emergency medical care.
3.
Teaching Staff :
The teaching staff on such a course should consist
mainly of health officers and teachers who,
themselves,
have a personal experience of rural health centre
services.
The challenge, put bluntly, is that health services and systems of
education must be organised for the good of the people, and not to
meet the personal needs of a certain cadre of doctors for material
gain or scientific satisfaction (TAYLOR 1970)
and if a shorter
course producing a new type of medical worker specifically trained
for the rural areas is the answer, then we must have the courage
and commitment to go through with the changes required. Only when
the needs of the rural areas are met, can the claims for Social
Justice within our constitution be validated.
It must,
however,
be remembered in India that the decision to
consider a revival of a shorter training course for doctors does
not mean that the existing M.3.3.S. course be allowed to continue
to develop along western trends. The decision to reorient this
course to meet the. needs of our expanding community health
services,
taken many years back, has resulted in many healthy
trends attempting to make the course more relevant to our local
needs,
and this must continue. The product of the system whether
he wants to be a general practitioner,
public health officer,
specialist,
teacher or research worker, must be made aware of the
19.
It
*
a o
V
)
local needs of his country, the economic limitations,
the
cultural factors that determine health trends, and the ne
develop local knowledse, local technology and local expertise.
must tie made to realise that
He
"no matter how useful a heart surgeon may be in the
right situation,
he is of little value in a country
where thousands of infants still succumb every year to
infectious diarrhoeas, and it would be far better if his
talents had been turned towards a more useful, if less
spectacular direction
(MARGUILLES, i960).
The process of making the existing medical education in India more
relevant to the country’ s needs is well under way (See Table J- )
out unless these new programmes and method s of teaching are
introduced wi th a degree of urgency into every medical college, the
effect of the reorientati on will be di f f i cul t, to assess.
TAHLE X
Reorientation
of
Medical
Education
for
Community Health Services (1973)
Initiatives
1. Creation of Departments of Preventive
Social Medicine
and
2. Community based Family Care Programmes
3- Course in Population Dynamics
Planning
Family
and
1. Rural and urban Field Practice Areas
5. Rural posting
internship
in
Compulsory
Rotating
6. Integrated inter-disciplinary teaching
7. General practice unit in teaching
OPD
hospital
3. Mobile training cum service hospitals
9. Student and Staff Health Services
It must te remembered that for such an orientation to
be
successful, we need staff trained in preventive and social medicine
and in the expanding field of community health, and there is an
acute shortage of such a cadre.
Certain principles to be followed
in this continuing reorientation should be stressed here.
•Jn iversi t.v Involvement in. Health Care :
3ryant (1969) has said that systems of health care are
inseparably linked to the education of health personnel, 'and
these systems cannot change without correspondinj changes in
education.
What is needed in India today is a strong
commitment of universities and medical colleges to health
care in the surrounding communities.
A medical college must
not consider itself a purely academic insitution, but must be
actively involved in the health of the community.
A first
step towards this commitment should be the allotment of a
primary health centre, and its subcentres to each medical
college in India.
The college should not only use the centre
for teaching, but also be responsible for its administration
and for the delivery of comprehensive health care to the
villages;
thus teaching and service become closely linked.
Greater involvement in health projects in urban areas like
urban slum health schemes, school health services, health of
specialised
groups in societies
such
as
destitutes,
prisoners,
industrial workers,
could also be initiated.
Finally, a medical college situated in an urban area could be
responsible for the total medical care of that region,
both
urban and the surrounding rural areas.
2.
lapco.Yem-e.n-t
Standards ox. Teaching and Taaeh.ex.a
In India,
as in all developing countries, there are acute
shortage of well trained medical teachers.
Most teachers
take up teaching because they have been unsuccessful in
private practice, or as specialists they feel that contact or
association with a medical college Improves their status and
prestige.
Teaching is thus seldom taken up as a vocation.
This is unfortunate, since the teacher is a key-figure in the
educational process.
Medical teaching in India can be
following measures are taken.
improved,
only
if
the
a. Teachers must be given a training in the basic principles
of education and must know how to produce effective
results with the available facilities.
b. They should be full-time so that teaching becomes the main
responsibility and not a side issue.
c. In order to get good teachers,
the salaries must be
improved,
and their social status raised.
Even the most
dedicated teachers can be put off by the present salaries
offered in India.
21
d. The teacher must be, himself, aware of the needs of the
community, and must be acutely concerned with problems of
health care and delivery in India.
He cannot pass on a
social concern to the medical student he teaches,
unless
he, himself is so motivated.
3.
Documentation &£. Local Knowledge mid. Needs mid. Development q_£_
Local Technology■ :
Any system of education which continues to follow textbooks,
primarily written for,
and dealing with the needs of a
western community, cannot hope to produce students aware of
local needs and disease conditions.
Textbooks of medicines
specially geared to features of disease and measures for
treatment prevention and control available in the country
are,
therefore,
urgently required.
An Indian
medical
student,
especially if he is expected to serve in the rural
areas, must,
surely,
know more about Hookworm
Anemia,
Amoebiasis, Malaria, Tuberculosis, Leprosy and Malnutrition,
than the information given in the textbook of medicine by
DAVIDSON.
At the same time he need not study,
in detail,
diseases such as Disseminated Sclerosis or Pernicious Anemia
which he seldom sees.
A special textbook or manual of
medicine to prepare him for rural health centre service on
the lines of KING (1966) would be very welcome.
Attempts to
develop local technology to design and produce medical
apparatus and equipment suited to our local needs,
budgets
and climatic conditions should also be encouraged.
U.
Appreciation
<a£ Economy .and Effective
Available Service mid Eesources :
utilization
<qf.
Health is only one of the many priorities in socio-economic
development and hence the financial resources available for
health care, education and development are limited.
In a developing country, like ours, appreciation of economy
and effort to initiate building constructions,
and health
programme which are realistic, must be stressed.
Often due
to social and political pressures we are tempted to build
large medical colleges and hospitals purely along western
standards and designs.
Very often these prove to be 'white
elephants' which are difficult to staff and administer,
but
more often than not, the building takes up the entire budget
and so remaines unutilized due to shortage of running
expenditure.
This situation has occured so often in India
that there is an urgent need to ban any further investment on
such projects.
In a country where the need is great,
the
quality and extent or care provided is far more important
than the aesthetics of size of the institution through which
it is given.
"For a proper and effective utilization of the available
resources,
it would be necessary to coordinate the
activities of the various health institutions in a
region.
In this way, duplication of effort and wasteful
expenditure on personnel and equipment could be avoided"
(MONTERIO, 1970).
(9A I AO
*
N
A?-'
COMMUNITY HEALTH CELSi
326. V Main, 1 Block
Koramangala
Bangalore-560034
India
22
This also means sreater utilization of
public nonteaching hospitals and medical
and dispensaries in medical education.
5.
existing private and
institutions,
clinics
General Practitioners .and. general Practice
To meet the health needs in India, there should be a much
greater emphasis on the production of general practitioners
rather than specialists.
This can be done by:
i) Introducing general practice units in
patients, as suggested earlier.
hospital
out
ii) Involvement of general practitioners of the area in the
teaching and training programmes of medical colleges
(MONTEIRO, 1970)
iii) Starting of a general practice speciality or department
in every medical college which coordinate (i) and (ii)
and also provides training for all medical graduates
interested in taking up general practice.
5.
evaluation :
It is necessary to determine the efficacy of many of the
earlier
suggested changes in the curriculum,
on
the
reorientation of students towards community medicine.
Unless
these programmes are subjected to well-planned evaluation
studies,
the effect they have on a student can never be
determined.
The only known study carried out on ' rural
internship,
for instance, is that by TAYLOR (1966)The
study revealed that 71% of the interns questioned thought the
rural experience was useful, 69% developed an ability to
establish rapport with the villagers, 57% learned to get
along with other professional colleagues and auxiliaries, 56%
got an understanding of the socio-economic factors
in
disease,
and 50% got a favourable idea of rural life after
the three month programme.
7. Motivation af. the Me.di.cax ?rofetalon
All over the world there has been a gradually increasing
materialistic orientation of the medical profession.
The
ideals of service and dedication are becoming rarer among the
doctors.
The outward manifestations of this change are
reflected by the shortage of doctors willing to work in rural
areas all over the world, by the shortage of doctors willing
to work in specialities like geriatrics, psychiatry, or any
field which requires a certain amount of dedication and also
in the development of health care systems such as in the U.S.
where the treatment one receives depends entirely on how much
one can pay; thus a time has come when the medical profession
must reappraise its own position in society.
The young
medical student plans his career in the image of his teachers
and elders in the profession and unless their motivation
changes,
the hope of producing community oriented doctors
remains idealistic.
23
However,
it is important to keep in mind that the motivation of
doctors to work for society in different countries is closely
related to the political systems and,
therefore,
a particular
experiment works in a country, only if the political system favours
it.
Finally, it must be remembered that health care and medical
education are only one of the many aspects of the entire life of a
country,. and the more commensurate they are with the country's
economic,
cultural, social and other conditions, the more likely
they are to succeed.
They also stand a better chance
of
influencing favourably those other conditions. A village health
centre is no loncer a curative dispensary but a centre providing
comprehensive health care which includes curative, preventive and
rehabilitative measures, environmental health, improved nutrition,
housing and recreation; in other words it is a centre involved in
the overall improvement of the life of a community.
Therefore,
a
doctor must be trained not only to be the head of a health team but
must be prepared to be a member of a larger developmental team of,
administrators,
farmers,
engineers, teachers and so on,
united
together in an effort to improve the conditions of Rural India.
E.£££.EE.Ii££S.
1. Bryant, J.
(1969).
Health and the Developing World, Cornell
Ithaca and London
2. Fendall, N.R.E.
Press,
Foundation,
John's
(1972)
Auxiliaries in Health Care, Josia Macy
Hopkins Press, Baltimore, Maryland.
3. Gish, 0.
University
(Ed) (1971).
Health Manpower and the Medical Auxiliary.
Technology Development Group, London
Intermediate
King, Maurice (1966).
Medical Care in Developing Countries.
A
Makerere. Oxford, University Press, Nairobi.
symposium
from
5- Marguiles, Harold (1966) .
Medical Education in Developing Countries.
Indian Journal of Medical Education, 5, 91.
6. Monteiro, L.
A
c omme n t ary.
(1970).
Aims of medical education in a developing country and the
facilities available, Indian Journal of Medical Education, 9,
258.
7. Planning Commission. India (1972).
Towards self reliance - Approach to the Fifth five-year plan,
Directorate of Advertising and Visual Publicity, Ministry of
Information and Broadcasting, New Delhi.
24
6.
Rao. K.N.
(1966c).
Educational adaptation to the factors bearinc on
Education in developing countries, Indian Journal of
Education, 5. 4899.
Rosa, Franz,
Medical
Medical
(1964).
A Doctor for Newly Developing Countries:
Principles for
adapting medical education and Services to meet problems,
Indian Journal of Medical Education, 39, 918.
10. Takulia, H.S.
Carl, E.Taylor, Sangal.S. Prakash
D.Allen (1967).
and
Joseph
The Health Centre Doctor in India, The John's Hopkins
Baltimore, Maryland.
Press,
11. Taylor. C.E.
(1966).
The Scientific Medical Culture and Rural
Journal of Medical Education, 5, 364.
Medicine,
Indian
(1970).
12. Taylor. C.E.
Community Medicine and Medical Education, Indian Journal
Medical Education, 9, 393-
13- Titmuss, R.M. and Smith, B.A.
of
(1964).
Services of
Tanganikya - a report to the
African Medical and Research Foundation, London.
The Health
Government.
14. TODD Report -
Royal Commission on Medical Education (1965/68)
H.M.S.O., London. '
15- Waddy, E.B.
-
Report;
(2963).
Rural Health Services in the Tropics and the training of
Medical Auxiliaries for them.
Trans, of Royal Society of Tropical Medicine and Hygiene, 57,
384.
Source: Final
chapter
of
Dissertation
Trends
in]
Undergraduate Medical Education Xn India zJ
Training
doctors
for
Community
Health!
Service■
submitted to London University for!
Diploma in Tropical Public Health, June 1973)!
25
(D) LESSONS ERQM
A YEAR QE TRAVEL ANU REFLECTION - xafiz
!□_ Background
: ' 1982 was an important milestone
in
our
professional lives.
After a year of travel to 'grass roots'
health
projects and a series of individual and
group
reflections on the challenges and dilemmas of community
health, we decided to move beyond the portals of a medical
college to initiate a technical resource centre in community
health focussing our efforts on community health action and
health activism.
This note tries to highlight the salient
features of the reflections and the reasons for our moving
beyond the teaching hospital.
2. During the years 1973 - 1981, the Department of Preventive and
Social Medicine of the medical college in which we were
teaching passed through a rapid phase of growth, in response
to
the
institution's
renewed
commitment
to
rural
reorientation of medical education.
During this phase seven
rural centres in which there were both health and development
efforts were organised. A unit of Occupational Health geared
to training and research programmes■in the plantations of
South India was also established.
A comprehensive rural
internship programme as well as rural orientation camps for
pre-clinical students were evolved.
A wide range of informal,
basic and continuing education efforts for community health
workers, doctors and nurses from rural health projects and
small
hospitals, plantation medical officers and
otherplantation health staff were also developed during this phase.
3- The work was most interesting and the field experience rich
and varied.
The leadership of the department and
the
institution was farsighted and progressive and most of us in
this phase got experience that was not only relevant but very
comprehensive too.
Few institutions in this
country can
boast of the phenomenal range of programmes that were built up
systematically during this phase.
ft. However,
over the years, we began to sense a
growing
alienation which we soon realised was both conceptual as well
as process related.
The conceptual alienation was with the focus and setting of
Preventive and Social Medicine as a subject in the context of
medical care and education.
The teaching of the subject was
academic and examination oriented.
Numerous compartmentalised
topics
had been put together under its banner.
In the
absence of integral links with the teaching hospital and
adequate insitutional commitment to effective, community field
practice areas,
the subject did not succeed in making any
impact on the attitudes of students or faculty
of other
departments and was gradually becoming just another subject
speciality rather than the means towards a more comprehensive
preventive and social orientation of medicine.
5. The process-oriented alienation was linked to the mechanism of
the growth of the department.
It seemed to us that there was
a quantitative growth of staff, facilities, courses and field
practice areas without a qualitative growth in planning,
research,
staff enrichment and programme monitoring
and
evaluation.
26
New and pilot programmes soon became routinised and due to a
constantly
changing staff pattern,
the working of
the
department often became ad-hoc and one of crisis management.
Programmes initiated as means to an attitudinal change,
gradually, became ends by themselves.
5. We soon realised that some of these problems arose from the
inability of most medical college managements to understand
and plan effectively for rural/'social reorientation of medical
education.
Firstly,
this reorientation process was most
often
misunderstood as the effort of a single department rather
than concerted efforts of the entire faculty of a medical
college.
The stress was, therefore, on programmes by ?SM
department rather than innovative modifications in the
teaching, service and research efforts of clinical and all
other departments.
Secondly,
there was always a dichotomy between
the
investment and inputs into a clinical ward and those
planned for,
in a community field practice area or
community ward.
This was not only in terms of available
senior faculty but, also in terms of supportive staff,
facilities and budgetary sanctions.
Thirdly,
there seemed to be insurmountable obstacles in
linking the community field practice ' area with
the
teaching hospital in an effective referral
services
complex as envisaged by the Government of India report on
Medical Education and Support .Manpower (Srivastava, 1375)
Fourthly, the needs and exigencies of transportation by a
community medicine department team was an area of much
misunderstanding.
Fifthly,
in the absence of a perspective plan to commit
adequate resources to a field practice area, to enable a
team of staff to live in the area and evolve an effective
community programme to be used for teaching purposes, much
of the staff involvement in the community was remote
control, tending towards 'armchair community medicine'.
in spite of the fact that the thrust in these years was very
much towards a process of rural reorientation all these
factors continued to Play their part in the evolving situation
even in this college.
7. Of ail the programmes mentioned earlier, it was the informal
training of community health workers,
alumni doctors from
rural hospitals, nurses from rural dispensaries and plantation
medical officers, that gave us maximum Job satisfaction and a
sense of fulfillment.
These training programmes gave us
adequate
scope
for experimenting with
non-formal
and
innovative training methodologies using a group dynamic.
problem solving approach. Supporting such groups, who would
actually be undertaking work in the community seemed more
27
fulfilling than preparing medical students or nurses for an
examination.
This informal,
alternative experience
also
helped us in becoming critically aware of the inadequacies of
our didactic,
rather compartmentalised medical
education
system.
3. Over the years we also gradually moved in our understanding
of health from its historic medical connotation of 'sickness
care' to the broader, positive definition of physical, mental
and social well being.
We became more aware of the socio-cultural and political
determinants of a health system and its close links and
interactions with the development process.
It seemed to us
that whereas the medical profession would continue to mop the
overflow of preventable illnesses through curative measures,
serious health professionals and workers should and could
initiate processes to turn off the tap of disease and ill
health at its very origins in the individuals life style,
attitudes, family life, community life and environment.
As these ideas began to dominate our thinking, we began to
get more interested in a wide range of areas and issues not
covered by orthodox medical education,
viz.,
alternative
approaches to health care; issues related to development and
socio-political change;
team building and group dynamics;
informal and non-formal pedagogy; non-drug positive health
therapies; non-allopathic systems of medicine including folk
medicine:
cross cultural conflicts in medicine; holistic
health and so on.
All
this supported a paradigm shift within
perspectives from 'sickness care
*
to 'health'.
our
own
5. Inevitably an active involvement with the field realities of
urban and rural field practice confronted us with social
issues
of
poverty,
inequality
and
injustice.
This
confrontation of value systems, life styles,
attitudes and
modes of team functioning and decision making was at both a
team level and a personal level.
Swinging between the mat
level simplicity of the rural centres and the ivory towered
affluence of the college and hospital was a constant tension.
Working with and among rural people also heightened our
sensitivity to the impersonal and dehumanising
medical
culture of our large, highly westernised model of college and
teaching hospital.
It also made us more than aware of the
cross cultural conflicts that the poor patients experiences
when they visit the hospitals from rural areas or urban slum.
10 .
Over the years,
our interest in the newer dimensions of
health brought us in contact with a large number of groups
and agencies like the medico-friend circle, Voluntary Health
Association of India,
SEARCH,
Indian Social
Institute,
Society of Young Scientists, Science for the villages,
CREST
and family Welfare Centre, Catholic Hospital Association of
India,
CM AI and Asian Community Health Action network.
We
28
participated as members or resource persons in meetings and
networkins sessions.
The awareness of the large numbers of
people
committed
to health work outside
the
formal
governmental or university network was a great support.
11. In 1331, some arbitrary decisions by the University affecting
the student community led to a crisis in the college.
During
this period we had the opportunity to organise a solidarity
movement to raise public opinion and the general conciousness
of the campus residents on such arbitrariness of authorities.
Apart from gaining some experience of the dynamics of
organising such a collective action, it also gave us an
understanding of the types of motivation of staff and
students on the campus.
At a deeper level, we understood an
even greater evolving crisis that the insitution was running
into -- in which the dimensions of lack of communication and
motivation; lack of continuity in processes and planning and
decision making; lack of participatory decision making;
lack
of
inculturation and value formation;
and pursuit
of
excellence out of the context of the pursuit of social
relevance were going to play an increasing part.
12. All the above factors led to a certain degree of work related
personal frustration and an increasing desire to rethink our
role in medical education and health care.
We therefore
decided to 'drop out' of the college for a year and spend it
visiting health and development projects in the country,
meeting friendg, colleagues, and community health workers, as
a process of reflection and evaluation of our own personal
work experiences and perspectives since graduation.
Overview
The year 1982 with all its component activities was a rich
and meaningful experience for both of us at a personal level
and well served its main purpose.
We visited a whole range of field projects and met committed
people from differernt ideological backgrounds which helped
to widen our horizons.
The contact with a wide circle of
people actively searching for ways and means by which health
and
development could be more meaningful
for
people
especially the rural and urban poor was inspiring.
We met alumni of our college working in small rural mission
hospitals and reflected together on some of the inadequacies
of the medical education in our alma mater with specific
reference to challenges of rural hospital practice.
We met community health workers in their own project setting
and observed the successes and failures of our training
programmes.
We identified pressures that were
pushing
individual CHWs beyond their capacity.
We also became aware
of the deviations from our training as well as its overall
limitations especially when individuals were working out of
context of a supportive infrastructure.
29 .
We met medico-friend-circle colleagues and a whole range of
health and development activists, who were involved with
evolving a wide range of alternative projects and processes
with the people. In our discussions with them, we focussed on
understanding their work in a process sense as it evolved
through positive and negative experiences.
The interactions
gave us a rich feed back of the imperatives of health and
development work in our social reality.
We read and reflected on many issues concerning our vocation
in greater depth than had been possible in the earlier years.
We searched for answers to many technical and
social
Questions facing us and though we did not always arrive at a
definite conclusion, we discovered points of contact with the
experience of others and identified processes through which
more meaningful answers could be obtained.
It. Being a personal quest, the effects of which we hoped would
be reflected in our future work, we did not plan to write a
formal report for the institution as such.
However, we list
out here some broad perspectives which evolved as learning
experiences from the year.
It is impossible to share the
whole experience just in a few paragraphs but the following
perspectives highlight the salient conclusions of the search.
SOME PERSPECTIVES
15. The positive physical,
mental and social dimensions of
health, both at an individual and community level have failed
to capture the imagination of the medical professionals and
medical educationists because of their historical
pre
occupation with 'sickness care'.
Years of a 'floor mopping' attitude to the overflow of
disease has resulted in what has been described as 'highly
sophisticated
curative
practices along with
all
the
paraphenalla of mystification, professionalisation and total
submission to the dictates of the drug industry
.
*
The new 'tap turning off' attitudes in response to the
people's needs as well as potential available knowledge
consisting of such ideas as —
primary health care;
health education;
demystification of medicine;
popularization of health producing
activities and attitudes;
strengthening of people's traditions
of self care;
communi ty organisation and participation
in health care.
and so on therefore continue to be viewed
resentment and inte11ectural opposition.
with
suspicion,
30.
The ethos of medical care and education, in rurally oriented
medical colleges like ours and others we visited during the
1931 trip as well as most of the health services under non
governmental voluntary agency auspices continue to reflect
this myopic medical view.
16. Ill health in the ultimate analysis is a direct product of an
unjust socio-economic political system which results in
poverty and inequality of resources and opportunities.
A
health team/health pro j ec t/'heal th institution, if it is clear
in its 'health
*
objective should inevitably become part of a
development process which seeks solutions for issues of
social injustice of which illness or disease are but a
symptom.
Health work would therefore become a development of
alternatives by which this process of democratisation is
extended to the grass roots, enabling people to shape and run
their own health services.
The team/project/institution must
internalise this democratic process within its own structure
as
a pre-requisite.
Hospitals,
dispensaries,
medical
colleges and academic health departments which are products
of existing structures need much internal change before they
can participate in such a process.
For a start they can
become less hierarchical, less elitist and more sensitive to
people, especially the poor and more participatory.
17. Those of us who function at technological levels in our
professional
capacities need to respond creatively
to
people's needs and evolve
alternative and
appropriate
frameworks
of
technology,
manpower,
processes
and
communication,
within the constraints in which our people
live.
Mobile clinics,
rural camps,
hospital
outreach
programmes and other such ideas which get doctors/nurses out
of institutions into the realities of rural village and urban
slum life are therefore only means.
The ends being the
adaptation of specialised knowledge and technical skills to
the situation of people's lives.
18. Especially
in medical colleges,
when such
ideas
are
experimented with as part of a rural reorientation process,
it is crucial to ensure that they are evolved through a
flexible process which stimulates voluntarism and creativity.
Otherwise what has happened in most situations is the
thrusting of frustrated, resentful faculty into a situation
outside a hospital setting where they dish out limited stock
of pills to a curious general public.
Each department needs
to understand the levels of care in the health pyramids,
the
types of workers available and adequately reorient their own
teaching to 'the best possible use of these resources under
each circumstance'
rather than 'the pursuit of an ideal
unrelated to social reality'.
As examples of this flexible
initiatives such as : —
creativty
one
may
suggest
pre-clinical department faculty organising human
biology teaching in village schools;
an G5G Department
for dais and ANMs;
organising
learning
sessions
31
An anaesthesia department experimenting
with
simple procedures for field anaesthesia including
acupuncture;
- a plastic surgery department organisinng a burns
prevention education programme in a
village
school.
A mobile clinic programme would then become a means to such
creative reorientation and as and when each department
identifies a more concrete, more socially relevant rol,e in
the community.
it could move beyond the mobile clinic. Only
if such creative interactions and freedom of innovation is
made possible can medical college faculty ever grow out of
their ivory towered isolation.
It must be kept in mind that
social/'communi ty orientation is a first step towards the
preventive and promotive reorientation of medical roles.
15. It is common place for professional institutions to talk
of
social relevance, rural reorientation and so on.
However,
more often than not, these have been attempted by a whole
series of adhoc. uninregrated activities representing ideas
of individuals rather than a thoughtfully analysed,
planned
process of change involving collective discussions among
faculty.
Changes in attitudes,
objectives and even
professional
direction can be brought about only if the institutional
management or term leaders are sensitive to process.
This is
as true of rural projects, small peripheral hospitals,
large
specialist hospitals or even a medical college.
A social
reorientation, of its activities and objectives can evolve
gradually through the acceptance of a need for : -
i. an understanding of the historical process and
growth of an institution/profession/activity;
ii. the overall social context in which it operates
and the new values or vision it wants to move
towards;
iii. a
setting
objectives;
of
clearly
defined,
measurable
iv. a participatory planning process which involves
formal and informal feedback and evaluation as
an integral component;
v. a team building approach in decision-making;
vi. a stress on the development
resources of the team rather
resources and structures;
of the human
than material
vii. a shared value system which shapes attitudes
and evolves practice of individuals within the
ins titu tion/projec t;
During the year of travel we came across some institutions
and projects who were going about this social reorientation
M P ' I 3>O
2-1 i+O
32
in a serious systematic way and it was through an interaction
with them that we understood all the components of such a
process.
20. Team work, professional, or social in any endeavour decides
ultimately its success or failure.
This was an important
learning experience.
Many programmes though committed to
health in community had not internalised "healthy team"
functioning within their.structure and the effects of this
incongruence were obvious.
Highly individualised efforts
pushed in a non-participatory set up were not uncommon where
orientation to achievement, overshadowed team development,
ultimately sensitive to this dimension, having arrived at its
need not always without a crisis in the project/team.
However, by realigning the objectives and methodology so that
team members were enabled, enriched and actively encouraged
to participate,
they were beginning to move towards more
integrated efforts.
This dimension was as true of the
interaction
between team members,
as it was for
the
interaction between team members
and villagers or the
community.
A partnership in development if it has to be
truly in a spirit of dialogue must go beyond divisions of
professional
/non-professional,
expert / lay,
educated
/illiterate, medical/ non-medical, provider/beneficiary and
so on.
That this was happening at least in some projects was
a good experience to observe.
Some aspects of this team work dimension that
from various expereinces were:
we
collated
a. evolution of mutually shared common objectives
roles through group work;
and
b. a concentration on strengths of individuals
than weaknesses;
rather
c. increasing
opportunity for sharing
feelings, hopes and experiences;
ideas,
of
d. a constant effort to internalise a shared value
system eg., in community health oriented efforts.
This may include healthy life styles and attitudes,
community
feeling,
simplicity,
non-hierarchical
functioning,
learning from the people,
adapting
technology etc.;
e. an
informality
relationship;
and
openness
in
inter-personal
f. a commitment
to learning from field experiences of
the entire team rather than just "theory".
This
would automatically mean a commitment to constant
experience analysis, critical reflection and review;
g. an
inculcation of participatory
planning and decision making.
management
in
Though much of this may seem unrealistic at first,
in our
present .highly institutionalised set up,
we
discovered
33
through interact ions with even institutionally based people
that institutions or structures by themselves were not
stifling: or limiting of such a process.
The major block was the formality of ideas with which
individuals, and decision makers choose to function within
them.
It was thus an attitudinal constraint not a structural
one.
21. One of the greatest dangers to any process of social change,
reorientation, relevance seeking endeavour is a rapid setting
in of institutionalisation including:
- routinisation of activities;
- formalisation of functions/relationships ;
- increased red-tape;
- fixity of roles;
- fear of precedence;
- discouragement or disregard for informal and
formal feedback;
- lack of adequate communications;
- inability of leadership to encourage, enrich and
support team members.
What was surprising was that many people saw team work as a
genetic attribute of individuals not an environmentally
stimulated response.
However, many others had discovered
that "good teamwork" does not just happen.
It needs to be
planned for and worked for. We even met teams who were
moving from a phase of hierarchical functioning to a phase of
participatory functioning patiently relearning attitudes and
seriously questioning past modes of functioning.
That this
was possible was heartening.
22. Having been part of a phase of rural reorientation of a
medical college before we embarked on this year of travel and
reflection, we could not help but critically review and
reflect on the process we had been part of.
Some overall
perspectives that emerged were: -
a. rural reorientation of medical education is a term
that needs to be changed since the need is not just
to focus on a geographical setting as an end in
itself but to focus on socio-economic and cultural
factors and issues relevant to health care.
These
are important in the context of the
community
interaction outside the hospital but are equally
important factors within the context of hospital
functioning.
The effort thus becomes a social and
community
orientation
of all
aspects
of
an
institution's efforts.
31*.
t>. the focus of efforts must not be to get Staff and
students to just physically move into rural areas as
an educational or service effort but to challenge and
change
attitudes
within
the
profession
and
institution stimulated by the perceptions from the
community experience.These attitudes would include: - desire to humanise hospital environment by
humanising
medical
team
patient
relationships,
and improving medical team
patient communications:
- encourajingt
demystification
of
knowledge and health education:
medical
- increasing sensitivity of hospital staff to
conditions of poor patients,
the
socio
economic factors under which they operate and
the cultural realities of their lives;
- making our technology subservient to people's
needs - not making people subservient to
professional, technical, institutional needs.
The
latter is possible only through
a
continuing
system
of social
audit
of
institutional services.
c. Such attitudinal changes which is the crux of all
efforts can seldom be brought about by orders,
bonding, pressures, monetary incentives, or indirect
coercion or disincentives even though each of this
may have a temporary effect.
The change can be
brought about only by: -
i. increasing role models in the institution by
better staff selection;
ii. open discussion
making ;
and
democratic
decision
iii. a constant and continued exposure of faculty
and students to all those already involved
in such work:
iv. analysing of positive and negative field
experiences
through a
problem
solving
approach;
v. a creative and flexible encouragement to
all suggested Initiatives by faculty and
s t uden t s.
d. An attitudinal change is a sensitive process and is
one area where the counter-productivity of hastily
applied, impractical, irrelevant, often super-imposed
methods should be constantly kept in mind
and
avoided,
eg.,
inadequately
prepared
or
I
35
undersupervised field exposure, planning insensitive
to the community's feelings and needs, publicity
consciousness in efforts and so on.
Such efforts
often result in a growing cynicism which is more
difficult to tackle in the long run.
23. It is important to record here that these perspectives were
gained visiting; people workins: both within formal
and
informal institutions,
projects and networks in health,
development and education.
In all of them there was a
healthy dialogue of whether existing team-institutions can
really internalise some of these newer perspectives and
processes within the existing constraints and established
relationships and modes of functioning.
In other words,
can
a medical college, a department of an existing: institution,
technology or specialist oriented hospital,
a
curative
oriented peripheral hospital, even a bureaucratised health
project, actually change their attitudes to support and build
people's health and people’s initiatives to sain greater
autonomy over the struetures/processes in society that can
promote their health?
Can existing ethos and frames of references of medical
insitutions
change so that rather than continuing
as
"providers of medicine" they could become "enablers of
health".
Source: Notes
From
an year of
Travel
and
reflection (1932) - a cyclostyled handout
circulated to peers and friends (CHC)
I
36
xL. SQXXHfi agYOND X1LZ. TEACHING HOSPITAL
(1989)
A Reflection an. Sama ExxQCta xawards an Alternative
Reorienting Medical Education to prepare doctors for -community
'cased health care in rural areas has been an interest of mine
ever since my internship experience in 1971, in a camp near
Calcutta,
for refusees from East Pakistan (now Bangladesh).
After three semesters of cadaver oriented pre-clinical studies
and six semesters of hospital-oriented clinical studies,
I
discovered
that my skills to meet the health needs of 5000
refugees squatting on less than an acre of land,
were rather
limited.
This was a thought-provoking experience and I was left
with
nagging doubts about the 'high technology',
'drug',
'institutional'
and 'foreign' orientation of
our
medical
education.
During my public health studies, I reviewed 25 years
of reforms in Medical Education in India (19-17-72) and studied
the experiences of introducing Preventive and Social Medicine
departments,
rural internship, slum based family care programs,
integrated inter-disciplinary teaching and the use of mobile
clinics and general practice units. All these were interesting
ideas added to the inherited edifice of medical education
mostly
tinkering
reforms,
not
a
radical
revision
or
reorientation.
Most medical teachers were products of the same
hospital-oriented system and lacked community health orientation.
Little real change in attitude could take place.
from 197-1 to 1933. I participated in a decade of efforts by the
Department of Community Medicine of my alma-mater ( a socially
oriented
medical
college in South India)
towards
rural
orientation.
We had to function within the existing constraints of the
university curriculum and the guidelines of the Medical Council
but these proved to be less of a hindrance to
of India,
experimenting with creative alternatives than we
had thought,
ini taily.
The challenge before us was to move beyond the orthodox 'banking
type',
fact-filled,
disease-oriented curriculum to a
more
experiential,
participatory,
problem-solving exposure in the
communi ty.
Students and interns had to be put in touch with the social
realities of rural India.
The educational stimulus had to be
geared to both the 'thinking' and 'feeling' domains of learning.
Processes initiated at the field level had to be flexible to
allow the student and/or intern to grow with the experience of
reality, countering the dominant hospitai-orientation and medical
culture.
I describe briefly two initiatives out of a
experiments which proved to be challenging
students and interns who participated in them
I
larger number of
for most of the
37
The first initiative was a sensitization experience during preciinical studies before the medical student entered the hospital
and underwent the brain-washing of the dominant hospital culture.
XitZTIATlYE _L RURAL vRZEHTATXGN CAMrS
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
social physiology of rural India and;
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 ao out daily in groups of twos and threes to
visit families in the neighbouring villages and elicit
information about various aspects of village life,
through informal chats.
The
first week focusses on communi t.v dynamics
agriculture, occupation, village government, health and
education
facilities,
markets,
transport
and
communication,
the second week on f ami l.v 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 villagers
during community 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.
Through 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
provides medical students to look beyond the medical
college walls to existing social realities.
The second Initiative described next was an experience
internship after final examinations were over.
during;
38
INITIATIVE J_ RURAL COMMUNITY HEALTH CLINICS
Interns,
who have completed a few months of hospital
based internships 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, initiatives and interest of the village
communities and development agencies.
The resource
mobilisation
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
organise 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
facili tators .
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 view the intern
as a participant in a process not a 'cog in the wheel'.
Many
are challenged, many are
experience the stark realities.
enthusiatic,
but
all
Both these initiatives proved to be of much personal satisfation
to staff and students.
However,
our experience over many years
of this type of community programs showed that long term
attitudinal changes vis-a-vis career options were not taking
place. No doubt the participant of such programs would turn out
to be a more socially sensitive doctor than the average product
of a medical college in India.
But his/her preference for an
urban,
high technology, .^specialist-oriented
hospital
base
remained powerful.
What the experience primarily showed was that alternatives geared
to innovations in the curriculum content of one department,
however relevant, would have little impact.
The whole ethos of
the
medical
college wcftild have to be changed
and
the
participation of all the ‘.faculty of all the departments would
have to be ensured.
Such .a process would ultimately lead to a
3'
INITIATIVE J. RURAL COMMUNITY HEALTH CLINICS
Interns, who have completed a few months of hospital
based internships 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, initiatives and interest of the village
communities and development agencies.
The resource
mobilisation
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
organise 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 view the intern
as a participant in a process not a 'cog in the wheel'.
Many
are challenged, many are
experience the stark realities.
enthusiatic,
but
all
Both these initiatives proved to be of much personal satisfat n
to staff and students.
However,
our experience over many ye s
of this type of community programs showed that long t m
attitudinal changes vis-a-vis career options were not tak .g
place.
No doubt the participant of such programs would turn
■ 't
to be a more socially sensitive doctor than the average prod; t
of a medical college in India.
But his/her preference for
n
urban,
high technology,
specialist-oriented
hospital
t e
remained powerful.
What the experience primarily showed was that alternatives gee vd
to innovations in the curriculum content of one departme
however relevant, would have little impact.
The whole ethos
f
the
medical
college would have to be changed
and
e
participation of all the faculty of all the departments wc .d
have to be ensured.
Such a process would ultimately lead tc a
39
radical
reorientation of the selection procedures,
course
content, pedaajojy and skill training in the institution.
The new
process would have to be located in a wider social context.
It is five years since I moved beyond the medical college to a
process of reflection and facilitation of community health at the
grassroots.
Through the "medico friends circle" - a national
network of doctors and health activists - a process has been
initiated
which seeks to outline an
alternative
medical
education,
deriving inspiration from the deeper analysis of
historical and social forces at work in our society and in our
educational process.
The publication of these reflections is
awaited.
The findings are, however, beyond the scope of this
reflection.
Source:
LINK.
Vol. 7, No 1,
April- May 1938
(Special issue on Training - Newsletter
of
Asian
Community
Health
Action
Network).
40
F.MEDICAL EDUCATION
- TQWARLE GREATER SOCIAL RELEVANCE
(X9S91
1■ Lessons from History :
The History of Medical Education in India spans several
centuries.
An interpretative history can be broadly divided
into four key phases, durinc which Medical Education evolved
and was influenced by the socio-cultural-political realities
of the times.
Eu_ Phase T
(i1 Ancient and Medieval India
India's
traditional
system
of
medicine,
called
'Ayurveda' (Science of life) developed dur-ins the Vedic
period.
Training of doctors in this sytem was through
apprenticeship
to
renowned
physicians.
Later'Gurukulas' or Ashrams of learning were started with
groups of pupils.
Records are also available of atleast
three institutes of Higher learning - Taxila,
Nalanda
and Kashi, where medical degrees were awarded.
The
authoritative textbooks or- Samhitas included those of
Char-aka (the Physician) and Susruta (the Surgeon).
The
two most renowned medical teachers of those times were
Atreya and Jivaka.
With the advent of the Buddha (500 - 600 AD) came the
development of a hospital system for- men and animals.
During this period the materia medica which hitherto had
been based mostly on herbal remedies, introduced mineral
salts (latrochemisty) .
However- surgery and human body
dissection, for teaching purposes, experienced a setback
during this time.
In a later phase (1200 - 1800 AD) Ayurveda and its
component
Medical Education experienced a
growing
stagnation due to lack of State patronage which resulted
in poorly equipped and poorly maintained
teaching
institutions.
Records
of the educational aspects of this
long
tradition show that the training methodology included
theory and practicals - lecture, discussions,
seminars,
practical compounding,
examination of patients
and
surgery.
There were theory and practical examinations
at the end of the course and a graduation ceremony where
a medical oath was administered, similar to the present
system.
Great care was taken in the selection of good teachers
and students,
in which both cognitive and affective
qualities were given importance.
The qualities of a
good teacher apart fr-om proficiency in the subject
included
e
practiced hand.
good
ohservati ons ■
disposition io teach■ Eliie. discussant. non-practicing,
gentle. dispassionate, pure conduct. pain and privation
bearing capacity and E person with no malice or wrath■
On the other hand, the good student apart from having a
broad
based education and
aptitude/intention
for
knowledge. needed to be PEXient,
’Dharmic’.
celibate.
Polite. non-violent. truthful. cure of body and mind and
nonhaughty,.
41
British colonalism on the other hand led to
the
establishment of the Madras General hospital in 1679;
the Medical department of the East India Company in
17U0;
the trainlnc of local assistants dressers and
apothecaries by IMS Doctors for the next eighty years;
the development of the native Medical Schools
in
Calcutta,
Bombay and Madras between 182^-1827
and
finally the Committee on Medical Education appointed by
Lord William Bentick in 1833 which saw the establishment
of Medical Colleges all over India firmly on the
European traditions and practice of those times.
The Native Medical Schools had a 3 year training in
Pharmacy, Materia Medica, Anatomy, Physiology, Medicine
and Surgery based on British textbooks and treatises
which were translated into Sanskrit and Urdu - both of
which were the medium of instruction.
The works of
Charaka,
Susruta and Avicenna were also studied and we
find here the first attempts at
'integrate on'
of
traditions.
The
recommendations of
the
Medical
Education Committee of 1833, saw the defeat of the
'orientalists'
by the
'Anglicists' especially through
far reaching reform of colleges (& - 6 years) with
English as the only medium of instruction
and the
principles
and practice of medicine taught
being
strictly in accordance with the European mode
of
practice and textbooks.
The colonial phase therefore saw the establishment of a
colonial medical education cut off from local historial
and cultural roots.
The phase 1833-1932 saw the establishment of the new
type of Westernised medical colleges all over British
India
by
the
government,
rajahs,
businessmen,
philanthrophists and eminent citizens.
Apart from the
subjects
taught
earlier in the
native
schools.
Chemistry,
Opthalmology, Jurisprudence,
Dentistry and
Hygiene were introduced into the curriculum.
Colleges
were affiliated to the newly developing Royal Colleges
of London,
Edinburgh and Dublin.
Through a gradual
transition, there was a socio-cultural acceptance by the
Hindu and Muslim communities of all aspects of Western
Medical Education including cadaver dissection.
Inspite of the 'Colonialist' dimension this phase also
saw some 'positive' aspects, the significance of which
cannot be underestimated.
Firstly,
was the development of
'Public
Health'
practice which made a dent on many of the major killer
diseases in India like Plague, Cholera, Small-pox and so
on.
Based on the European tradition this was a new
dimension to the organised health traditions in India
which till then had been mostly medical and individual
patient oriented.
While these did not develop uniformly
all over India but were concentrated mostly in and
around the British cantonments and adjacent civilian
areas, it still had a tremendous impact on the health of
people.
42
.(11) — The Medieval Eitaae.
The Moghul invasion in the 12th Century AD. led to the
introduction of the Graeco-Arabic system established as
Unani through a chain of medical schools and hospitals
(bimaristans) all over India.
Based on the Hippocratic
tradition this system interacted with the established
tradition and cross-fertilised it.
Textbooks
were
translated into Urdu and medical education was through
either apprenticeship or private practitioner linked
schools or schools attached to big city hospitals.
Pharmacy developed as an important and independent
discipline and qualified pharmacists (Sadyalinatasi) and
drug inspectors (Muhtasib) were appointed in the health
services.
The materia medica gave importance
to
minerals and metals.
While the medical education pattern was similar to that
of the Ayurvedic tradition, treat stress was laid on
Medical ethics;
full time teaching was considered an
honourable profession;
and the good qualities of a
teacher included a £c^xsl build ■ deft hand. eves fx££. from
disease. not greedy, sensitive Xq. dirt and
ma and
tears and. strong minded but kindDue to taboos in
Islam, however. Anatomy and Surgery were neglected.
LESSONS
The key lessons from the system of Medical Education
ancient and Medieval India for medical educators
today include:
in
of
- the integration of theory and practice;
- the stress on healthy living and positive aspects
of health;
- the careful selection of teachers and students,
in
which affective qualities were given as much
importance as cognitive skill;
- the broad based, background education of students,
and
- the close integral links of the
local and established culture.
education
with
b. Phase XL m Advent of. Western Medicine
This
phase
which began in 1510
AD,
with
the
establishment of the Royal Hospital in Goa saw the
advent and establishment of the European tradition of
medicine and medical education on the Indian sub
continent .
Portuguese colonialism led to the rudimentary medical
teaching by Cipriano Valadares at the Goa hospital in
1703,
followed by the 3 year course of Miranda and
Almeida in 1801 and the establishment of the Goa Medical
School in 18U2 and the Naval Colonial School of Medicine
in 1888.
4*
the health services were key recommendations apart from
suggestion XQ abolish the 1icentiate course
have only
the
one
t-vpe gX. doctor x. the MBBS doctor.
The
Constitution of Independent India,
adopted in 1950,
accepted the 'Right of citizens to public assistance in
sickness' and the newly developed
Planning Commmission
adopted the Shore Commitee recommendations as the blueprint
for planning medical aid,
public health and
preventive
medicine in the country. (9)
The first All India Conference on Medical Education in 1955
saw the development of the scope, aim and requirements for
Preventive and Social Medicine departments in all medical
colleges, which would be the key facilitators for
the
social/community
orientation of services and
education,
envisaged by the planners.
The Mudaliar Committee - Health
Survey and Planning Report, (1959), recommended consolidation
of existing colleges along the lines already laid down and
introduced the compulsory pre-registration internship as well
as the concept of community field practice areas for PSM
departments.
In i960 the Indian Association
for
the
advancement of Medical Education was established and the
Indian
Journal
of Medical
Education
launched.
This
association and Journal became a forum for continuing dialogue
on relevant medical education.
In 196U the Medical Council of India spelt out the details of
the
PSM
curriculum
and also outlined
some
of
the
administrative,
preventive and clinical objectives of rural
internship. While encouraging social orientation through the
above,
it also tried to keep up with,, the West by suggesting
introduction of Genetics,
Bio-Physics,
Electronics,
Space
Medicine,
Molecular biology,
Radio-isotopes and
Nuclearmedicine as well.
In 1970 the Medical Education Committee
(Patel) finally defined the Basic Doctor- the preparation of
whom had to become the objective of undergraduate Medical
Education in the country. (Refer Box 1 )
BOX 1
The Basic Doctor
"Conversant with common problems of Rural
urban communities. ..
and
Able to play effective role in curative and
preventive aspects of regional/National health
problems...
Good clinician,
comptetent
referral is needed...
Able to give life-saving aid
emergencies...
Constant advancement of
continuing education."
to
judge
when
all
acute
in
knowledge
(Patel, 1970)
through
45
By the 1970b many Medical Colleges had introduced
PSM
Departments and had begun the recommended teaching
and
postings in rural and urban field practice areas.
While most
paid lip service to the detailed recommendations, many were
serious in their attempts to re-orient the orthodox system.
The developments of innovations by these medical colleges
within the existing constraints included the establishment of
a well-staffed PSM Department and its gradual orientation to
the dynamics of community oriented field practice; the concept
of a Family health Advisory service by medical students; the
development of internship programmes for rural and urban field
practice including family planning postings; the development
of the curative/preventive/general practice (CPGP) units in
medical college hospital OPDs; the development of the Mobile
training cum service unit hospitals (the government sponsored
Chittaranjan Mobile hospitals); the concept of student/staff
health service and so on. (9)
Beginning in 1972, when the country celebrated its Silver
Jubilee,
a new introspective spirit was seen in Government
documents and expert committee reports about the failure of
the .'medical education system 1 mi post-independent India
making any impact nn the social/communi t.v orientation mf. the
graduate doctors mm the health services ■ The V Plan document,
the VI Plan Document, and the Srivastava Report
(Report of
Group on Medical Education and support Manpower,
1975) were
all uniform in their indictment of the present medical
education and its increasing irrelevance to the country's
health problems and people's needs.
The Srivastava report made a very comprehensive analysis of
the situation and diagnosed the problem as multi-factorial.
(refer Box 2)
BOX 2
"Diagnosis, of the Problem"
-"Stranglehold of the inherited system
- exclusive orientation towards the
hospital
teaching
- irrelevance of training to community
needs
- increasing trends towards PG
specialisation
degrees
health
and
- lack of incentive/r-ecognition for rural work
- attractions of the export market for medical
manpower
- links of
Medical Education
to
social
framework is brought about only at the end
of the course during the intership."
- Srivastava Report, 1975
46
concluded that
'Medical Education postpones rather than
doctors for practice
medicine ±n the community 1
leadins to the VI Plan document (1979) exhortation for the
1 need Xc. restructure medical educational programmes xa. change
skilis/knowledees/attitudes
while
restructuring
society
towards social .justice .
It
prepares
The late 1970s thus saw the end of this 'nationalist growth
phase of Medical Education' with a growing disillusionment of
the inadequacies of the attempted medical reform on the
inherited western medical system.
review of the development till 1979 (Narayan
many lessons from this 'Nationalist Phase'.
19SH)
Firstly. the'colonial mental!ty' had been well
'brown sahet’ culture of independent
in the
planners and educators accepting separate types
for rural and urban areas
for the classes and
established
India with
of services
the masses.
A
draws
Secondly,
the populist rhetoric of health care for the
masses while at the same time keeping up with the west in
the urban areas had exposed our pseudo-socialism.
Thirdly.
there had been a concomitant
dilution
educational standards due to a growth pattern that
stressed quantity over quality.
of
had
Fourthly,
the sc.hizophecnift in. our educational objectives
which included going west and going rural at the same time
also had become evident and counterproductive.
Fifthly,
teaching in medical colleges had not become a
vocation and the qualities of the available faculty was far
from satisfactory.
The overall stress of MCI recommendations had been on
' content'
and not 'process' of education and as the MCI
recommendations of 1981 themselves accept that there had
been
no. evaluation nor- experimentetion on sc! ent if ic
i 1,
s~.. .
Finally,
the PSM departments which were considered to
become the harbingers of change had,
by their
very
existence generated some new myths which were becoming
problematic for the system.
Foremost among of these were
that :
i. Clinical medicine and PSM (Community Medicine)
were two different types of medicine and the
latter was a poor quality,
ad-hoc,
community
based version of the former.
ii. In addition community/rural/social orientation
was seen as the responsiblity of the PSM faculty
and not that of all the teaching faculty of the
medical college.
47
It was no surprise therefore that, as these myths cot well
'chances' in medical education made little
established the
dent in the attitude and orientation of the medical craduates.
It is unfair to draw only negative lessons from this important
phase and one would like to record that, these thirty years of
post-independence history, had also seen the establishment of
some medical care centres and medical collece departments
both undergraduate and post-graduate of excellent quality
their services and training, beinc second to none in the world
as evinced by the fact that craduates of many of these centres
were doing very well in their specialities and had received
acclaim, both national and international.
However, it is this
very pursuit xf. excellence and Hixx technology oriented
medicine unrelated to social relevance and social cost which
has
heightened the disparities and dichotomies of
the
health/medical scene in India.
These
successes notwithstanding,
expert
committees
and
national
policy documents have been unversal in
their
acceptance of 'failure' and exhortation lx 1 chance',
Foremost
of these have been the Srivastava Report (1975) which calls
for a
' conscious and. deliberate decision xo. abandon
the
existing model and strive to create i nstead a viable and
economic alternative suited lx our own conditions■ needs
and aspirations, '
This was followed by the ICMR/ICSSR Health for All,
report
which
endorses
all
the
Shrivastava
recommendations and.exhorts medical educators to
Strategy
report
' abandon Xhe flexnerised mxixL xd education * and adopt x
holistic■
inter-disciPl inary approach' which is more
field oriented and practical and which is based on a
close
collaboration xf. medical colleges with
the
health services,
Finally the 1982 National Health Policy Statement, the
in thirty five years calls for
first
i. Review of the entire basis/approach towards
medical/health
education at all levels in
terms of national needs and
priorities.
ii. Restructuring of curricular/training programmes
to
provide
professional competence
and
social motivation for day-to-day
problems.
II■ Search for Sxe.ater Social Relevance
- The initiatives in the 1980s
The 19o0s has seen a new spirit of introspection and
innovation though it is too early to judge whether 'in the
collective’ these efforts will demonstrate a real concrete
change in the situation or a continuation of the status quo
promoted by a more strident rhetoric.
However the 'need for
change' is now an established fact. .
The key developments and initiatives of this decade
the followinc.
include
ICMR/ICSSR Hefor All Report lias, outlined
some aspects of an 'Alternative Health Care System' that
needs to supplant the existins system (refer box 3).
It
is
more than obvious that the
'orthodox
medical
education' system cannot prepare professionals to serve
in such a system and therefore there is need for a
concomitant development of an alternative system of
medical education.
tjifi.
i.
Box 3
A health care system which combines the best
elements in the tradition and culture of the
people with modern science and technology,
- integrating
promotive,
curative functions
preventive
and
- democratic, decentralised and participatory,
- oriented to people
- economical, and
- firmly rooted in the community and aiming at
involving the people in the provision of
services they need and increasing
their
capacity to solve their own problems.
ICMR/ICSSR, 1980
2.The
Medical
Council
of
India's
curriculum
recommendations of 1982 bring together all the previous
key reforms and suggests even further innovation which
support the gradual move towards an alternative.
The key recommendations include :
- Increased integration of course
- More fundamentals and less sophistication
- More community based education
experience
- Emphasis on independence of Judgement and self-education
- Reduction in didactics and increase in
experiences
group
learning
- Focus on common community problems in all subjects
- Clinical
emergency
teaching to be focussed on
and peripheral health centres
outpatients,
49
- All faculty to be involved in rural centres
- Teachers trainins in Pedagogy and Community Health
The PSM curriculum was further strengthened and spread
over the entire syllabus.
It included three months of
pre-clinical
training
including
hospital
and
conununity/project visits, three years of concurrent PSM
teaching during clinical years with practicals,
field
visits,
postings in PHCs, rural hospitals and urban
health
centres
as
well
as
participation
in
preventive/promotive programmes.
It finally recommends
a 6 month internship experience in PHC's, peripheral
centres, FP clinics and rural projects.
3. The ROMc. Experiment
Though launched by the Janata Government in 1977,
the
Rural
.Orientation
Xlf Medical Education
programme
finally got off the ground in the 1980s.
Based on the
Srivastava
Report
recommendations
the
experiment
included the allotment of three PHCs per medical college
and the provision of three mobile clinics to involve
faculty and students of all departments in supportive
services and field exposures in the community, moving
beyond
the teaching hospital.
In principle
this
programme is a concrete step towards the community
orientation of medical education.
In practice however
the experience has been varied but mostly negative.
An
evaluation by. a JNU researcher in 1984 of the situation
in two states - Karnataka and Haryana showed that the
learning experience for students from thi's programme was
nil,
the wider objectives were ill-understood by both
the
students and faculty and there was
official
indifference as well from the concerned government
health • departments.
A few colleges have
reported
positive experiences especially if they have used their
initiative
and
modified
the
guidelines
through
experience.
U. Ebe Kqtie-yam experiment
An experimental project undertaken in Kerala in the
years 1972-76 to create a new category of health worker
a liaison between the hospital doctor and
the
community evolved an aproach and curriculum which has
great relevance to all those who are keen to experiment
with an integrated, community oriented and field based
curriculum.
However being in the NGO/Mission sector
this project did not have the. larger impact it should
have had and lead primarily to changes in the B Sc
Public Health Nursing syllabus in Kerala as well as
acted as a stimulus to the Health Assistants course in
Tamilnadu and the B Sc Health Science course in Osmania
Unversity, Andhra.
This project is unfortunately hardly
known in medical education circles.
50
5. innovations hx seriouE medical £.p.lle.g££
While the MCI curriculum recommedations of 1982 provide
adequate opportunity for innovation within the existing
system only a few medical colleses have used this new
opportunity for chance. Atleast two medical colleges in
the
Mission sector CMC (Vellore) and St.
John's
(Bangalore) have been known to have tried out a varying
range of programmes foremost of these being the Rural
orientation programmes/camps for pre-clinical students
and the socio-epidemiological community oriented block
postings for clinical students and community postings
for interns.
JIPMER (Pondicherry) in the government
sector has been another innovater.
Though their efforts
have not necessarily brought about attitudinal changes
or community career options among the students to the
extent
intended,
they
have
definitely
provided
meaningful
inputs into a community awareness
and
orientation of the practice of medical graduates of
these institutions, which is no small achievement.
6. The Medico Friend Circle■
An informal national network of doctors and health
activists concerned about making health care and Medical
Education more relevant to the needs of the poor in the
country
have focussed their attention on
Medical
Education through a series of meetings and reflections
since 1983,
stimulated by the efforts towards
an
alternative Medical School, by the renowned Gonoshasthya
Kendra Project of Bangladesh.
An Anthology of articles
entitled 'Medical Education : Re-examined' which will
soon be out of the press has among other things a first
preliminary draft of an alternative curriculum.
Will
there be any takers !!
7. The Alterngtive Tuach
Stimulated by the experiments undertaken by members of
an evolving International Network of Community Oriented
Health Sciences Institution in the world, the idea of an
Alternative track - an experimental parallel curriculum
is being considered by MCI and a few institutions in the
country since 19S8.
This would include problem based
teaching of the McMaster University Model
(Canada),
Community
orientation on the model of
the
ROME
experiment
in India and learner centred
teaching
pedagogy.
The alternative track is expected to have 7
units of 7 months each, two
devoted to human biology,
three to Primary Health Care and two to tertiary health
care.
Though still in the planning
stage,
the
experiment if it comes through will be a concrete
expression
of change.
CMC Ludhiana,
one of
the
participating
institutions
has
been
the
most
enthusiastic recepient of the idea.
51
8. A series of developments in the latter half of the
1980s other than the above show some potential for the
future. The New Education Policy enunciated by the
government in 1986 has several new thrusts which could
have a bearing on the scope and content of technical
education in the next decade.
A consortium of institutions including AIIMS
(New
Delhi),
Benaras Hindu ' University
(Varanasi),
CMC
(Vellore) and JIPMER (Pondicherry) have been formed in
1987 to explore 'Decision based approaches Xo. Evaluation
and innovation Xn Medical Education' based on the
methodology
enunciated by Centre
for
Educational
Development Illinois (USA).
Two State Governments, Tamilnadu and Andhra Pradesh have
operationalised the formation of Health University while
a third, Karnataka is in the process of considering such
a development.
While the preliminary efforts have been
mainly in the direction of standardisation of training
and
facilities,
the possibilities
for
potential
innovation in the context of health orientation are
many.
The Department of Social Medicine and Community Health
of Jawaharlal Nehru University has recently made a plea
for a new Public Health and Medical Education which
would stress historical perspectives;
epidemiological
approaches;
political economy of health
and
add
ecological/social/cultural
dimensions
to
existing
efforts.
The’ Miraj Manifesto towards an alternative
effort
prepared by CMC, Miraj is another concrete example of a
new commitment to innovation.
The Phase of Medical Education in India committed to the
evolution
of
'alternative
options'
and
'social
relevance'
has therefore seen a good beginning in the
1980s and the next decade will see hopefully some
committed alternatives to the goal of Health for All by
2000 AD.
XXX c. Challenges nnd XasKa. before the CMC Network
In the first section I have reviewed the important events in the
long history of medical education in India and drawn some lessons
from the positive and negative dimensions of this evolutionary
growth.
In the second section I have focussed on numerous
initiatives and developments in the 1980s which augurs well for
the new phase of innovation and highlights steps towards a more
relevant curriculum.
This is particularly important since we are
now entering the final decade of this century and have now set
for ourelves the goal of 'Health for All by 2000 AD'.
The emergence of a network of Christian Medical Colleges,
to
dialogue together and explore new dimensions, collectively, is a
posltlv,
step in the context of the future.
In this final
section
I will look at some tasks and challenges for the
network
COMMUNITY HEALTH CEL!,
0^
130
326, V Main, 1 Diack
Koianiongala
Bsnga lore-660034
India
52
The Christian Medical Colleges in India have played an important
role in the establishment of model medical institutions committed
to
quality
education,
humane
patient
care,
efficient
administration and increasing commitment to community needs.
They have pioneered historically medical education for women,
hospitals and services for women and children,
specialist and
super-specialist education and community medicine orientation of
undergraduate training among other things. However, in the past
they have done this primarily as individual
institutional
commitments functioning primarily within their own universe
(minority
Christian
institutions) and
focussing
on
the
complementary network of Christian medical insitutions in the
country.
The staff and alumnus of these insitutions have in
addition played a pioneering role in various
professional
associations and institutions as well as in the establishment of
community oriented health projects and training in the country.
A time has therefore come to first to take stock of these
achievements and the network could initiate sharing and dialogue
sessions that explore the strengths and weaknesses of these
achievements and initiatives.
Learning from the experiences of
each other and from the initiatives
their alumni could be a
first task.
A second task is,
they could move beyond the
'Christian
experience'
and
1 earn . from and explore wj th all
those
institutions.^ groups and. initiatves .that simm a. similar social
commitment in patient care■
quality medical education
and.
community health,
A third task of the Network would therefore be to build a new
ethos n£. collaboration and. cooperation - building on the past
histories and present strengths of each insitution.
These three tasks, which could be among the initial goals of the
Network would help to re-examine the
'contributions ' and
'developments' within the group of Christian medical insitutions
and reaffirm those aspects of their shared value system and
commitments that have shaped their evolution.
They would in the
process,
especially with Task two identify and
recognise
'partners'
and initiatives within the wider secular Indian
situation with whom future collaborative and supportive actions
could emerge.
This is particularly important since in response
to the commitment of being ’leaven in the bread' - Christian
insitutions
have
a role in focussing beyond
their
own
insitutional needs and goals to the wider society in which humane
values need to be established and strengthened.
Before discussing the fourth task, it is important to explore
some disturbing dimensions of the health care services and
medical education system which have been developing all along but
have definitely shown an increase in the
1980s.
While the
earlier review of the 1980s in the second section, affirmed some
of the positive developments towards 'rethinking and experiments
with alternatives in health care and medical education' a series
of simultaneously evolving negative trends have called into
55
question the future direction of health care and
medical
education in the country.
Firstly, we have the growth of
capitation
fee medical colleges which link admissions
to
donations and fees for seats. While no one would deny the need
for private enterprise nor par-ental/'public support foi’ funding
technical education to support the government's role,
the
experience of these insitutions has been geared to exploiting the
'money factor' not only in admissions, at the cost of the merit
student from a low income category, but in other aspects of
training and development as well. Government institutions are
being allotted to some of these institutions at the cost of
government training centres. Taken together these developments
reflect the politicisation
medical education
Secondly,
there has been a growing privatisation of health care
and a gradual corporate sector takeover of health.
This has led
to an increasing glorification of 'high technology diagnostics'
and high technology medical care often at the cost of basic
health care for the majority.
There is an increasing 'doctor
drug producer axis' creating 'vested interest in the abundance of
ill health'.
The private practice orientation is spreading in
government institutions and among medical college teachers and
there is an incrase in monetary considerations for 'services' as
well as promotions, transfers and posting.
All these symbolises
the increasing commercialisation
Medicine■
While
discussing
Community/Social orientation
of
medical
education as a new direction it is sobering to remember that the
'politicisation' and 'commercialisation' of health care and
medical education is rapidly taking place in the country and
therefore
the
fourth task of the network
of
Christian
institutions would be to resist these forces by continuing to
teach good quality, ethical, rational medicine' and exemplyifying
it in them day to day insitutional practice - while at the same
time searching for alternatives and exploring new dimensions in
health care.
The fifth and more challenging task before the network is to use
the 'collective opportunity' to critically examine all aspects of
current
medical/health
care
and
evolve
strategies
and
initiatives,
to improve the quality, the social relevance,
and
the ethical and wholistic aspects of it.
A whole range of issues
would come under this collective scrutiny.
Ethics,
pedagogy,
appropriate
technolgy,
rational
therapeutics,
rational
investigations and surgery, health team concept, social vision,
community oriented priorities, pastoral care,
accountability,
humanisation of medical care, spiritual values in institutional
practice, participatory management, social justice within and
outside institutions, health policy, quality assurance of health
care and so on. The collective endeavour would also help to
identify
'creative
responses and ideas
for institutional
reorientation.
Finally and most significantly the network could seriously
explore and experiment with alternatives in medical education as
well as 'training of health manpower' which are more strongly
committed to a social vision and a community orientation and are
54
more likely to provide the
'technical competence’
and the
'emotional preparedness' of graduates to serve the needy and the
underprivileged in the most disadvantaged areas of the country.
While this is in no way more significant than the other tasks
outlined earlier, it would probably be the most relevant response
to the Christian vision of 'preferential option for the poor'
within the context of medical education.
REFERENCES
1.
O.P.Jaggi (1979)
History of Science, Technology and Medicine in India
Volume 23, Atma Ram & Sons, New Delhi
2.
The Srivastava Report (1975)
3- The ICMR/ICSSR Health for All Report (1981)
ll.
Recommendations of Medical Education for Community
Health Services (Patel 1968, GOI)
5- The National Health Polocy, 1982
6.
Recommendations on Graduate Medical Education MCI, 1982
7.
Banerji.D (1988) - Trends in Public Health Practice in India
(JNU, New Delhi)
8.
Joseph.P (1986). A Sociological Enquiry into ROME Scheme
(JNU, New Delhi)
9.
Narayan.R (2973)
- Trends in Undergraduate Medical Education
London University dissertation
10. ibid (1977)
- Research in Methodology of Health Delivery
CSI/FPF Project Report
11. ibid (1984)
- 150 years of Medical Education:Rhetoric and Relevance
mfc bulletin 97-98, Jan-Fev 198/1
12. ibid (1989)
- Initiatives towards the Alternative
mfc anthology 'Medical Education Re-examined ’
(in press)
13- ibid (1989)
- An Anthology of Ideas : An alternatove curriculum
(mfc anthology - refer 12, in press)
111. National Education Policy, 1986
Source:
Keynote
address at
First
CMC
Network
meeting in August 1939.
Later
published
in
Christian
Medical Journal of India Vol VI,
April - June 1991. No 2
55
AN ALTERNATIVE VISION QE EDUCATION EON
.CARE (1990)
DECENTRALISED
HEALTH
1. Background :
The
Rational
comprehensive
Health
Policy seeks
primary
health aaxa services relevant
to
provide
'universal
Ha
the
actual nfifida. and. priorities a£ the community at a cost which
the people can afford, ensurins that the planning
and
implementing of the various health programmes is through the
organised involvement and participation a£ the community,
adequately utilizing the services being rendered by private
voluntary organisations active in the health sector'.
In the context of this commitment to 'decentralised' control
of health care it identifies the need to review the entire
basis and approach of current training programmes in terms of
national needs and priorities and recognises the 'cultural
gap' between people and the personnel providing care,
brought
about by the present policies.
It calls for a restructuring of curricular and training
programmes towards community health orientation;
integrated
team concept; and towards professional skill and competence
as well as
'social motivation' to 'handle day to day problems
within existing constraints'. It emphasises the crucial need
to monitor the process and review the efforts.
In addition it reiterates the need for a National Medical and
Health Education Policy which would include suggested changes
in curriculum at all levels;
inter relationships between
health
functionaries;
realistically
assessed
manpower
requirements and efforts to correct regional imbalances and
availability; as well as social motivation towards Community
health Services.
Finally accepting that 'the recommended efforts,
on various
fronts would bear only marginal results unless there is a
nation-wide health education programme"■ it calls for 'public
health education ■
supplemented by health nutr-j tion
and
population fiduaaTdQn in all educational institutions
at
various
levels',
further complemented by
'promotion
of
universal education': specially adult
family education ' .
Since it was the first comprehensive statement of policy,
in
nearly four decades it was an important milestone.
However,
if the content of the policy statement is critically analysed,
we discover nothing new.
From Bhore Committee (19U6) onwards,
through the Mudaliar Committee (1959). the Medical Education
Committee (Patel,1968), the Kartar Singh Committee (197^), the
Srivastava Report (1975) and the ICMR-ICSSR Health for All
Report
(1981)
all
expert
committees
and
policy
recommendations have said the same thing: What : Need to reach all people with basic care
Need to involve people in planning/organisation
Need to transcend cultural gap
1
56
How: Review all training programmes
Change curriculum
Community Health orient and motivate all
manpower
Assess manpower requirements and train
realistic numbers
Supplement with Public Health Education
All these previous committees have made several volumes of
recommendations - most of them adhoc and empirical but
relevant all the same.
•Srivastava Report sums up
the
situation well : -
"We have no dearth of ideas on the subject and
if all the recommendations made by educational
committees and commissions were put one after
the other, instead of going round and round in
circles as they often do, we may have a ladder
stretching: from the earth tc the moon"
The report further adds that while the focus all along has
been on educational content (type of change needed), there has
been little attention to creating appropriate structures for
educational change and hardly any attention to processes of
initiating change and carefully nursing them to grow.
It is important to stress here that in keeping with the
recommendations, some reforms have been constantly implemented
at different levels in the last four decades.
These include
the creation of Preventive and Social Medicine Departments in
Medical Colleges;
th'e introduction of complusory rotating
internship
including rural/public health
postings;
the
broadening of the scope of PSM teaching in Medical Colleges
extending throughout trie course; the experimentation with the
HOME Scheme and so on.
Domicary midwifery and some degree of public
orientation was also included in the nurses training.
health
The creation of the cadres of Health Supervisors, multipurpose
workers,
trained dais and community health volunteers or
village health guides and the establishment of the rural
health and family planning training centres tc train them was
also a step ir. the right direction.
However impressive,
the quantitative expansion of health
manpower in four decades may seem, the qualitative assessment
of the situation leaves much tc be desired.
The Srivastava
Report observes:
S: "There 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 as an enterprise
of
Science and technology;
the physician
is
the
repository
of
all
knowledge
and
dispensation;
specialisation is the hall mark of progress;
and the
training ground is the teaching hospital.
57
* Doctors
are still largely urban based
distribution between states is uneven.
and
* The training of nurses has not made equal progress,
in numbers.
their
even
* Inspite of the ’vast proliferation of the number and
types of para-medical personnel, the growth of the health
care services has been haphazard and unrelated to the
needs of the poor and rural people who stand most in need
of care.
* Over centralisation of authority and compar-tmentalisation
still plague the services.
* The health personnel structure is still
distorted;
instead of a pyramid it is more like an hour glass".
The end results of the efforts in Public Health Education have
not been very promising either.
Inspite of the setting up of
the Central Health Bureau and State Bureaus in 20 States and
Union Territories;
the production of bulletins
journals,
technical reports and films by CHEB as well as diploma and
short-term training programmes; introduction of the health
education component in almost all the national programmes
including the family planning programme, the report observes
that
* Health attitudes of the people have hardly changed.
* Health education programmes have hardly made any
on the situation.
impact
* There is little rapport between the health services and
the general education services - and neither of them have
been able to reach the underprivileged poor.
*'■ The programme of health education has remained anemic and
academic.
Even though the Srivastava Report was commenting on the period
1975 and before - the last fifteen years have not seen any
major or dramatic change in policy or implementation.
ir. 1989,
the present government has committed itself to a
radical decentralisation of the Health and Education Sectors.
At this juncture we need to relook critically at the present
situation of manpower education and health education,
to
understand the deeper issues of the malady and to explore
approaches and processes that may help us go beyond the
present
situation of relevant recommendations,
populist
rhetoric, and inadequate reform.
58
SCOPE
PAPER :
In this paper I would like to approach the whole problem
educational policy for a Decentralised Health Care by -
of
Firstly, providing a scenario of the present situation at the
community level to which the educational policy must respond.
Secondly, I wish to highlight the salient and
crucial
dimensions that must find expression in the policy framework
and formulation.
Thirdly, I wish to highlight certain positive initiatives
contributions that should be carefully studied to provide
concrete basis for reform and reorientation.
and
the
Fourthly, I wish to highlight certain important trends in the
country
which
though inimical to the
concept
of
a
decentralised health care are well established and need to be
countered by such a policy.
Fifthly, I wish to provide a Philosophical matrix against
which all efforts in Education for Health have to
be
contextualised,
so that the process initiated,
is
both
responsive and relevant, to the socio-economical-politicalcultural realities that exist in the country.
THE ’COMMUNITY SCENARIO'
:
The policy of Panchayatraj and the formal involvement of
people in the planning and implementation policy, through it,
has been on the books for years but has been concretely
attempted at the grassroots mainly in Karnataka and West
Bengal in recent years.
The village community today, as before remains a heterogenous
community stratified by class,
caste,
gender,
religion,
geography and education.
Health
Care Services are inappropriate
culturally
and
inadequately accessible to most. Where accessible it focusses
and caters to those who have money or power and it is they who
will participate in any decision making in health if at all in
the Panchayatraj System, at the community level.
The large majority of landless and marginalised are unreached
by the primary health centre services for the same reasons
that affects their involvement in education,
development or
political power.
The local health traditions, folk medicine and indigenous
systems of medicine and the dais provide some cure and relief.
Where this is inadequate or fails, they (poor) are forced to
find relief in the growing private sector in health often at
the cost of wages and increased indebtedness.
The Primary Health Centre doctor and the team of health
supervisors and multipurpose workers are unable to respond
creatively to this reality due to many reasons of which three
are crucial.
59
In background and values they are alienated from
majority of the village under-privileged .
the
large
Their training and skill development is in a
training
environment heavily influenced by the ’medical model’ and
strongly curative and technological in its orientation.
They have little understanding of social analysis or societal
processes
or of participative pedagogy
or
awareness
building techniques.
In
addition
being part .of
a
top-down,
centralised,
hierarchical planned and vertically implemented health care
system,
they are mostly preoccupied with the targets and
measured actions in Family Planning or immunization or other
selectivized primary health package deals.
The doctor who leads the team is emotionally unprepared and
professionally
incompetent to handle the situation
and
therefore fills his time with private practice,
coercive
health
education,
statistical Jugglery and health
team
policing if he is not visiting the Directorate,
seeking an
urban transfer.
The health team has little understanding of the sociological
or epidemiological dimensions of the local situation,
since
the over 20 records and registers maintained and tabulated,
are primarily for a monthly statement transferred to a
district MIS that is preoccupied with providing invalid
statistics for the State, Central governments and Planning
commission
rather
than
for
critical
education
and
decentralised planning at the grassroot.
Decentralisation of
Health Care must locate itself in this rather unfavourable
climate.
t. UlMEIiSiQiiS.
EDUCATIONAL POLICY :
If an Educational Policy has to make a dent in a
such as the one described above, then it must be
and creative in a host of ways.
situation,
responsive
a) Basic Manpower Training
* The Doctors, nurses and paramedical auxiliaries have
to undergo basic training in an environment which is
more community oriented and community based than at
present and. which provides 'professional skill and
competence' and 'emotional preparedness' to practice
medicine and health care in conditions of limited
resources and difficult environment,
seeing it as a
• professional challenge / opportunity rather than an
unavoidable
obligation.
Field
practice
areas
outside the teaching hospital have to be facilitated
and all the faculty oriented to provide meaningful
learning experiences to the trainees.
Though the curriculum of each member of the team has
to be reviewed and suitably modified the so called
Community Health Orientation which is so often
60
mentioned in policy documents should consist of a
core curriculum which would involve a)
Social
Analysis, b) Orientation to Local Health Culture and
Indian Systems of Medicine,
c) Holistic
inter
disciplinary Problem Analysis,
d) Experience of
Alternative Pedasoey, e) Participatory Management,
f)
Appropriate Technology,
a) Interactive
and
Qualitative
Research and Monitoring,
h)
Socio
Epidemiological
Orientation,
and
i)
Awareness
buildinc and Health Education Skills.
b) Continuing Education:
* While reform is basic training in a long term
solution and a distant possibility, the existing PHC
team has to be given a well planned and creative
reorientation
programme
as
a
commitment
to
continuing education which will seek to convert them
to a new development culture including the following
components among others
* The recognition of people as 'participants'
not 'beneficiary'.
and
* The importance of a Social/Societal analysis to
help in a positive discrimination towards those
groups who do not participate in or utilize the
present systems.
* Skill and competence in an information transfer,
health education and awareness building process.
* A sensitivity to feedback from people and an
increased commitment to learning from grassroot
experience - personal or that of co-workers.
* A sociological and epidemiological orientation
that helps to move understanding and initiative
from individual to
collective/community levels
and encourages a more holistic problem analysis.
* The recognition of diversity
flexibility of approaches.
of
options
and
* The appreciation of interactive and qualitative
approaches to programme evaulation and not a
preoccupation with quantitative, indicators.
* An
adaptability
to
modify
or
create
technological options to suit local situations.
c) Pert icioatory Management Education :
a: At both basic and continuing levels the whole
process of education should promote an integrated
team concept and promote a process of collective
discussion and decision making and counter, actively
the
present day values and characterstics
of
hierarchical
functioning,
individualism,
gender
61
discrimination,
education/profession
linked
superiority and so on.
This will enhance not only
the
intra team interactions but will
greatly
encourage
a
more democratic
/'
participatory
interaction with the people and representatives of
the community which is the basis of Panchayatraj .
If health team members do not experience this
democracy in their training programmes or their day
to day PHC functioning, they are unlikely to be
motivated or skilled to facilitate this at the level
of the community.
d) Community ,Ed.u.C-ati.Qn
* Even if,
through reforms in basic training and a
commitment to continuing reorientation of existing
PHC staff, we are able to encourage the formation of
professional/skilied manpower to facilitate
the
demands of decentralised Health Care there is still
the equally crucial task of community education■
The people at large and the formal and informal
leaders
in particular have to
experience
an
awareness building and orientation programme which
has to go way beyond the 'lecturing'
or 'telling
them' style of leadership training camps presently
organised by the Health Department for
Family
Planning and Immunization.
These sessions need to
be dialogue based and using audiovisual techniques
that are low cost and folk culture sensitive.
The
rush to use TV and Videos as a short term solution
must give way to a more purposive focussed and
interactive process reaching all those who dp not
get reached at present.
The use of puppetry and
street
theatre,
folk
arts
and
festival
entertainment, jathas and street corner meetings or
shandy exhibitions etc., need to be widely promoted
and utilized.
The experience of the peoples science
movements in Kerala and Maharashtra and other NGO
media groups is very relevant to these efforts.
e) Heal11 in Priroar-y
* Finally while interactive civic education and health
education directed at the present polity
must
precede decentralisation a comprehensive input of
health/nutrition/and population education must find
an important place in all educational efforts
formal -and informal at all levels and particularly
but primarily,
at a school level so that
future
citizens,
more attuned to the participative demands
of a decentralised health care are
available.
School health programme actively involving children
and teachers through creative 'learning by doing;
techniques is a crucial input.
While all these suggestions may appear at first, to be not
dissimilar to many offered by experts and others before, there
is
a qualitative difference in the scope,
focus
and
orientation of the process being suggested.
What has failed
in the past is not just the content but the process of
education
and
the . pedagogical ..culture.
..it. . is ...this
'alternative' culture that is being stressed in this paper.
62
5. AJi OVERVIEW DE ALTERNATIVE EDUCATIONAL EXPERIMENTS JJ£ INDIA :
There
is a tendency in the country for
experts
and
educationists to make adhoc and empirical generalisations
about
curriculum
chance
without
promoting
active
experimentation or evaluating ongoing initiatives or for that
matter substantiating through micro-level practice at least
the validity of the suggested reforms. Most are not even
aware of what little experimentation is actually going on.
It
is true that for a country as large as ours with a contigent
of nearly 30C medical colleges - nursing colleges and
paramedical training institutions, the quantum and quality of
relevant experimentation or reorientation efforts has been
rather limited.
There are however still numerous projects and
initiatives that have explored crucial dimensions and need to
be seriously studied by planners and policy makers to evolve
an educational policy for Decentralised health care on more
sounder foundations.
* The description of these initiatives in any detail is
beyond the scope of the paper but a brief overview is
required (refer Appendix I) to atleast substantiate the
contention that there has been experimentation as well as
record appreciation for these efforts, inspite of the
prevailing
bureaucratic,
highly
centralised
and
professionally
controlled,
medicalised,
hospital
oriented, educational environment.
* These alternative experiments have taken place both
within and outside the profession educations system.
The
innovaters include teachers in medical colleges and
community-, health
trainers
in
the
NGO
Sector.
Coordinating groups like CHAI, VHAI,
CMAI and issue
raising health activist groups like mfc have
also
organised programmes or developed alternatives.
* Outside the health sector a number of
alternative
training
experiments have emerged in the
informal
education and development sector that have relevance to
health manpower training or public health education.
* All
these
trainers have
experimented
with
more
participatory forms of training and generated a number of
case studies,
role plays,
simulation games,
learning
exercises and community based problem solving techniques
that provide a firmer foundation to the educational
programme outlined earlier in the context of promotion of
decentralised health care.
Having been closely involved with training in both the formal
and informal sector for nearly eighteen years, I am convinced
that there is available a wealth of alternative pedagogical
experience that could be tapped by the health planners and
policy makers to make the suggested educational programmes a
concrete reality.
Presently in fact a few of us are part of an interactive
research project that is putting together this rich Indian
experience into a handy 'reference manual of local innovation,
65
an Antholoty of ideas emerging from local experience,
and a
resource directory of local expertise
.
*
Hopefully this will
be of great relevance to the health ’manpower trainer
*
and
public
health educator who wish to organise
education
programmes
to
support the policy
initiatives
towards
decentralised Health Care.
6. BROADER .ISSUES US. TEE CONTEXT DE EDUCATION DE EEALTE :
Education for Decentralised Health Care cannot take place in a
vacuum.
It must be contextualised to the emerging socialeconomical-cultural-policitcal realities and trends in the
country.
Notwithstanding a growing commitment and enthusiasm
among health planners and policy makers to the concept of
Decentralised Health Care, especially in more recent months,
there is no doubt that there are larger more disturbing trends
emerging in the Health Care Scenario, which can neither be
ignored nor brushed aside as unimportant and which are
basically inimical or counter to the whole decentralisation
trend.
Only two of these will be highlighted here,
though
there are many more.
Firstly is the growth of capitation fee medical colleges which
link admission to donations and fees for seats and which have
also geared the money factor to other aspects of training and
institution development.
Linked to these is the growth of institutions based primarily
on communal considertaions.
Both these types of institutions
continue to get state level recognition inspite of objections
by MCI and Central Government.
Government institutions are
being allotted to such groups at the cost of government
training programmes.
These trends reflect the increasing
politicisation of Medical Education.
Secondly there is a growing privatization of Health Care and a
gradually increasing corporate sector takeover of health.
This has led to glorification of high technology diagnostics
and high technology medical care often at the cost of basic
health care for the majority.
There is an increasing 'Doctor
drug producer axis
*
creating a 'vested interest
*
in the
abundance of ill health.
The private practice orientation is
spreading
in government institutions and among
medical
colleges teachers and there is an increase in monetary
considerations for 'services
*
as well as promotions, transfers
and posting.
All these symbolise the Commercialisation of
Medicine.
.
Both
*
'Commercialisation
and 'Politicisation
*
are
not
accidental.
They reflect both government policy action and
inaction and are leading to a gradual erosion of the values
among health manpower and the disappearance of good, rational,
ethical, medical and health practice.
This is a cause for
serious
concern
and urgent policy
counter
offensive.
Decentralisation of Health Care and involvement of people in
Health Care decision making, planning and organisation will
remain policy rhetoric if these wider more ominous trends are
not checked.in time.
All of us committed to HFA - 2000 and to
the increasing involvement of the Community in their own
Health Care, cannot ignore these trends.
64
7. THE FARADXSK SHIFT :
Kevins outlined £ multi dimensional educational response to
the promotion and support of the concept and policy of
Decentralised Health Care which would include a) Community
Oriented
Health Manpower Training,
b) Community
Health
Orientation of Trained Manpower, c) Public Health Education
and Leadership Orientation and d) Health in Primary Education
and
having
also suggested a 'core' of
'issues'
and
'dimensions' that must form an integral part of the 'community
health orientation' and 'social motivation' at all levels and
in all these training programmes I would like to- conclude with
a final suggestion.
All efforts in Education in Health in the 1990s must be
located in a paradigm shift that has been taking place in our
understanding of Health and Health Care from the orthodox
medical model to the social model £l£ health that attempts to
tackle ill health at its deeper roots.
This Paradigm shift is characterised by a multi-dimensional
shift in emphasis - in all aspects of health,
health care
research and training as shown in the accompanying box:
!
!
XHE PARADIGM SHIFT
Medical Model to Social Model of Health
[
1
’
-- >
COLLECTIVE/COMMUNITY
[
[PATIENT & POPULATION
-- >
PERSON & SOCIETY
[
[PHYSICAL/MENTAL
[PREDOMINANTLY
-- >
PHYSICAL/MENTAL/SOCIAL/
CULTURAL/POLITICAL/ECONOMICAL
J
[DOCTORS/NURSES
[MEDICAL AUXILIARIES
-- >
TEAM OF HEALTH WORKERS
[
[DISEASE PROCESSES
-- >
SOCIAL PROCESSES
[HOSPITALS/DISPENSARIES
[DRUGS/TECHNOLOGY
[-PROVIDING SERVICES
-- >
HEALTH PROMOTING AND COMMUNITY [
BUILDING CENTRES AND PROCESSES-;
ENABLING/EMPOWERING THE PEOPLE [
[INTRACELLULAR RESEARCH
-- >
SOCIETAL RESEARCH
[
[PATIENT AS BENEFICIARY
[AND CONSUMER
-- >
PEOPLE AS PARTICIPANTS
[
[PROFESSIONALISED
[COMPARTMENTALISED
[MYSTIFIED KNOWLEDGE
-- >
[QUEST FOR VACCINE
[AGAINST DISEASE
-- >
[INDIVIDUAL
>
i
[
[
[
[
DEMYSTIFYING, PERSON CENTRED
AUTONOMY CREATING
AWARENESS BUILDING KNOWLEDGE
[
QUEST FOR AWARENESS BUILDING
PROCESS TRO IMMUNIZE AGAINST
UNHEALTHY SOCIAL PROCESSES.
[
[
[
[
[
65
The succ.eas
.the strategy xz£ Decentralised Health Care and
the educational efforts ho bring lx about wiAl depend very
ditch an how £f£ectiyely health planners, policy makers,
educationists .and researchers and the health team are able to
adapt themselves ho hhis. changing matrix.
1. Ministry of Health and Family Welfare (1983)
national Health Policy
GOI, New Delhi.
2. Central Bureau of Health Intelligence (1985)
Compendium
Recommendations nf. various committees on
Development 19^3 - 1975
DGHS, GOT, New Delhi.
3. Ministry of Health and Family Planning (1975)
Health Services end Medical Education
a
Immediate Action (Shrivastava Report)
GOI, New Delhi.
Heal th
for
Programme
a. ICSSR and ICMR (1981)
Health £or All =. An alternative strategy
Indian Institute of Education, Pune.
5- Community Health Cell (1989)
People’s involvement in planning and implementation process,
CHC, Bangalore.
6. Community Health Cell (1989)
Community Health in inhls
Health Action - Vol. 2, No. 7. July 1989-
7. Narayan, Ravi (1988)
Initiatives
Towards an. Alternative', Medical
examined , MFC Anthology (Now in print).
Education
Re
8. Community Health Cell (1990)
for Social Relevance and Community Orientation
Medical Education
Building from the Indian Experience
An interactive Research project outline.
Strategies
An
66»
ADDITIONAL NOTES
TRAINING EXEEHEMEKTE RELEVANT TC THE EEK EDUCATIONAL VISION
WITEIN THE SETTEE
* A few medical colleges in the country have experimented, with
community
orientation,
within the
constraints
of
MCI
recommendations and though the multi-dimensional efforts, may
not have produced a marked change in long term career choices
among their graduates for community health, it has definitely
provided some of the 'professional skills’ and the
'emotional
preparedness' that expert committees have mentioned as being;
crucial.
Foremost among them are CMC-Vellore, MGIMS-Sevagram,
SJMC-Bangalore,
AIIMS-New DElhi, JIPMER-Pondicherry and CMCLudhiana.
Two of these CMC-Vellore and SJMC-Bangalore have a
rural placement (bond) scheme that ensures that many of their
graduates serve 2 years in a peripheral community oriented
hospital project and render meaningful service.
* Many departments of medical colleges have experimented with
providing 'learning experiences' beyond the 'teaching hospital'
through rural orientation camps,
rural/urban family health
advisory schemes, rural/urban field practice areas and block
postings; curative and preventive general practice units ruralurban community based health education programmes,
socioepidemiological projects, mobile training cum service units and
extended community based rural internship.
* The Jawaharlal Nehru University has organised M.Sc.,
M.Phil.
and Phd. programmes in Community Health which goes beyond the
orthodox public health or preventive and social medicine
postgraduate programmes to provide students with a historical
perspective,
epidemiological approach, political economy of
health as well as a sensitivity to focus on ecological social
and cultural dimensions in health efforts.
* The Medical Council of India and a few institutions have been
working on an experimental parallel curriculum which is problem
based,
learner centred and community oriented. One of these
institutions,
CMC-Ludhiana, has already been given the green
signal
by the Punjab University to go ahead with
the
alternative track from July 1991.
* A consortium of institutions including AIIMS (New Delhi),
BHU
(Varanasi),
CMC (Vellore) and JIPMER (Pondicherry)
has been
formed in 1987 to explore 'Decision based approaches to
Evaluation and innovation in Medical Education' based on the
methodology of CED Illinois, a US based -WHO linked resource
centre for Education innovation.
S: Two State governments,
Tamilnadu and Andhra Pradesh have
operationalised the formation of Health Universities.
While
the preliminary efforts have been mainly in the directions of
standardisation of training and facilities, many potential
innovations in the context of health orientation are possible.
67.
OUTSIDE THE SYSTEM
» ,7i>e Kottayan Experiment in 1972-76 created a new category of
tseaSttj worker as a liaison between the hospital doctor and the
eonc-tity through an integrated, community oriented field based
turrlculuin - which was a pioneering effort.
* Tbe
medico friend circle - an informal national network .of
doctors and health workers has recently brought together an
alternative medical curriculum entitled 'Anthology of Ideas',
which explores the broad framework of a community oriented and
community based medical college.
This is derived from an
ar.thology of reflections on medical educaton by some of its
core members entitled Medical Education Re-Examined
* The Miraj Medical Centre has formulated a plan of a Community
based Medical Education experiment, circulated recently as the
Mirai Manifesto and is awaiting the go ahead from Central and
State Authorities.
* After- years of Primary field level experience many community
health training programmes have emerged in the voluntary/NGO
Sector focussing on Community health orientation and skill
development for medicos and non-medicos.
Varying from 6 weeks
to
1 year they all promote community organisation
and
development,
community participation,
demystification
of
medicine and training of local health workers.
Key among them
are the leadership course in Community Health and Development
(Deenabandhu),
Community Health and Development Course (INSA,
Bangalore) Diploma in Community Health Management (RUHSA
and
VHAI),
Diploma in Community Health (Ambilikkai),
Community
Health Planning, Organisation and Management Course (VHAI) and
others.
* In addition to the above NGO health trainers there are a
growing number of training and orientation courses in non
health, development sector which have evolved content, pedagogy
and attitudinal orientation of great relevance to health
manpower education as well.
The SEARCH Apprenticeship in
Development
(Bangalore),
the
TRACE
animators
course
(Maharashtra),
the initiatives of the Behavioural Science
Centre (Ahmedabad) and the training programmes of Indian Social
Institute (Bangalore and New Delhi) as well as ICRA Bangalore
are examples of such courses.
Source: Proceedings of the National Workshop on
'Towards a Decentralised Health Care : A
fresh look at the National Health Policy,
National Institute of Advanced Studies.)
September 1990, (In press)
,
68
APPENDIX i
FEEDBACK FROM PIONEERS QE A RURAL BOND
A.
SCHEME L12W.
BACKGROUND :
In the last few years some graduates of St.John's Medical
College (SJMC) have undertaken the two year rural placement
scheme organised by SJMC in coordination with the Catholic
Hospital Association of India (CHAI).
To-date little over Ixo
doctors have either completed the scheme or are currently
undertaking it in different parts of the country.
For most of
them this has been an enriching opportunity.
There was a growing need perceived by many of them.
to get
together to share their experiences, reflect on the work
undertaken and discuss
issues arising out of this experience
in the areas of hospital policy, medical education and the
placement scheme itself.
It was thought that such a group
reflection and review would be a meaningful feedback to the
organisers of the scheme, the faculty of the college and the
members hospitals of the CHAI network.
It would also be a
starting point for collective action by this group that has
been linked together by this common endeavour.
The matter was put to the CHAI and others informally and such
a session was made possible by the CHAI invitation to these
doctors to come together at SJMC on 19-20 May 198b.
B. OBJECTIVES
The main objective ■-pf this first workshop was to give all
these pioneers an opportunity to share their experiences and
reflect
together on all aspects of this scheme.
The
reflection would be introspective - to identify the key
factors during the educational phase and later during the
placement phase,
which encouraged, supported and motivated
these doctors in their commitment to the scheme.
Conversely
such reflection would also identify factors which hindered
this process or acted as obstacles to it.
It was hoped that
from this reflection would emerge some critical and thought
provoking feedback in many related areas, eg.,
a. Reorienting and strengthening the medical education
process in SJMC to make it more relevant for future
participants of the scheme;
b. Supportive and continuing education strategy for those
who opt for the scheme and/or those who Join peripheral
hospital practice on a longer term basis;
c. Policy issues relevant to small hospital
practice
especially
in the areas of patient care,
drugs,
investigations and staff;
d. Perspective
future.
for
individual career
decisions
for
the
C.
WORKSHOP METHQD.QLQgX :
Only those doctors who had completed the scheme or had done
atleast 6 months of it were invited for the workshop.
19
doctors out of 28 invited,
attended this workshop.
The
sessions were planned on a croup dynamic basis where the
pariticipants themselves planned and facilitated the process
and focus of discussions. Some alumni and staff were also
invited to be present at this review.
The first day's programme consisted of an initial session of
sharing of experiences followed by small-group discussions and
a plenary session. On the second day the participants got an
opportunity to meet and share their findings with the CHAI
team and resource persons attending the CHAI Community Health
Departments annual review meeting.
This was followed by a
meeting with the heads of departments of SJMC called by the
Dean to consider this important feedback by the past students
of the college (who had made it possible for the college to
meet partially the objectives of the college).
D. RECOMMENDATIONS
MEDICAL EDUCATION :
There has so far been no concerted effort to think of adapting
or modifying the undergraduate training that students receive
at SJMC to serve any special need since the RBS scheme itself
took birth only three years ago and the number of graduates
opting for it was quite small. However, with the increase in
the penalty amount a situation will soon arise wherein the two
year stint in a rural hospital will become an integral part of
thg course,
like the compulsory rotating internship.
With
this change in trend, we feel strongly that the process
leading to graduation should be so modified that at the end of
our 5 1/2 years course, we are specifically equipped to work
meaningfully in rural areas.
Drawing on the individual experiences of the pioneers and
reinforced by a detailed discussion amongst us and a few
alumni staff, the following points emerged with regard to the
training we have received till the time we settled down to
practice in the rural hospitals.
Studentship :
1. We are convinced that the process of training should begin
with the entry of.the student into the .course. The .rural
orientation camp for the First MBBS students should be
suitably planned in order to give them an early insight not
only into an introduction to the aspects of rural life but
also an introduction to the practice of medicine in rural
areas.
It would, therefore, be desirable to post them to
work in the sub-centres under the SBI project at SJMC for a
week or so during which they will actively assist the
interns in their work (like helping with
dressings,
procedures and dispensing of medicines etc).
70
With the entry of students into their- clinical postings,
they should be entrusted with graded responsibilities in
the actual management of hospital patients and .should not
remain mere spectators of the daily ward/OPD routine as at
present.
Irrespective of the departmnet to which they are
posted they should be by rotation posted ’on duty' in the
wards.
During such postings they will be expected to stay
in the ward for
hours with the teaching and house staff
of the concerned units. Students on such duties could . be
exempt from lectures/ clinical classes/practicals with
separate arrangements to have these and their tests fixed
on non-duty days. In the wards they will be exposed to
opportunities
to master various nursing and
medical
procedures .
Schedule of graded responsibilities could be
during the clinical years
a. X
follows
as
Semester:
Maintaining daily vital signs record,
diabetic
urine chart, urine albumin chart, nephritic chart
etc.
Administering
IM
injections,
simple
dressings.
b. XI Semester:
Passing Ryle's tube, giving enemas. Mouth and eye
care,
maintenance of
intake/output
record,
monitoring of post-operative patients,
special
dressings,
simple physiotherapy like active
passrye exercises,
ambulation
of
bed-ridden
patients,
assisting at medical and
surgical
procedures, assisting at normal deliveries etc.,
and compulsory casualty postings.
c. XXX Semester: •
Giving IV injections, starting IV drips,
drawing
of
blood
for
investigations,
conducting
deliveries,
assisting at forceps extractions,
assisting at minor surgery,
recording EKG's,
assisting at complicated dressings,
therapeutic
procedures like condys compresses,
ECT's,
out
patient surgical procedures.
d. XY Semester:
Assisting major surgical procedures, doing simple
post-operative dressings, doing O.P. dressings,
suture removals, assisting house staff in side
lab
work,
helping the
CMO
in
casualty
procedures,
physiotherapeutic procedures
like
postural drainage, gait training etc., assisting
at caesarian sections.
During this time students may also be sent to
other/Government institutions for training in the
fields of traumatology & truama
management,
71
obstetrics etc where the availability of clinical
material at St.John's would be found insufficient
or inadequate.
e.
V
& VI Semester:
These 12 months shall be spent in completely
equipping the student to independently function
as a full-fledged doctor.
In short he shall be
carrying out all the functions interns are at
present carrying out, except not being involved
in decision making independently.
During this
period too,
arrangements may be made in other
institutions to have our students trained in
fields where St.
John's is yet to
develop
adequate potential.
Internship :
From the present situation in which internship is a period
where skills are acquired there is a great need to utilize
this period to promote the capacity for independent decision
m-aking.
Proficiency in skills will be completed during the
undergraduate clinical years as suggested above. Unlike the
situation in a teaching institution where a battery of
consultants affords a protective umbrella, the young doctor in
a rural hospital has to take decisions on his own with no
possibility, t.o a 'second on call', being, around, to .offer
advice. So it is imperative that the intern not only learns to
take
decisions but also takes considered
and
correct
decisions.
This
is
possible only
if
there
is
a
decentralisation of decision-making process in each department
and unit.
From the time bound, theoretical programme that it
is now, a qualitative change should be effected in internship
to make it a procedure and competence-based programme.
This
means that the professors will take the responsibilities of
turning out a full fledged skilled and confident doctor at the
end of internship. Some of the changes could be Medicine :
A greater emphasis should be laid on management of
disorders by low cost rational drug therapy.
An
intern should also have done these procedures during
his training - (a) endo tracheal intubations;
(b)
paracentesis; (c) lumbar puncture; (d) aspirations;
(e) sternal punctures etc.,
Surgery :
Common procedures like (a) catherizations ; (b) liver
biopsy;
(c) incisions and drainage;
(d) excision
biopsies; (e) herniorraphy; (f) hydrocele relieving
procedures;
(g) insertions of chest tubes;
(h)
plaster of paris - slab applications for fractures;
(i)
circumcision;
(j)
emergency
side
lab
investigations and so on must be undertaken under
supervision often enough to be skilled in attempting
these in the future situation of the rural hospital.
„ .
*• .ih’-..£)-,& I ft C'- ■
j.t
/ ' “
!£>!'
'
,
COMMUNITY HEALTH CELL.
356, V Main,,I Block. ■
;
Koramangala
Bangalore-560034
India
72
Skill in procedures such as (a) forceps extraction;
(b)
pudendal
and other
blocks;
(c)
breech
extractions; (d) D & C; (e) instrumental evacuation;
(f) caesarean section; (g) vacuum extractions;
(h)
suturinj of perineal/vulval/cervical lacerations;
(i) • manual removal of placenta; (J) versions;
(k)
side lab investigations in emergencies must be
ensured by supervised participation in situations
when such procedures become necessary.
Community Medicine :
From the present posting of interns to sub-centres
where their work is a passive general practice,
a
change should be made to posting interns (especially
those who are definitely taking up the
rural
placement scheme) to work in hospitals under the
scheme along with the graduates already working
there.
This will not only help them to develop
relevant perspectives for such work but will also
help them to identify areas where they should pay
special attention during internship.
Other Postings :
1. Postings
in
Paediatrics,
Orthopaedics,
Opthalmology ,
ENT, Dermatology and Psychiatry
should be compulsory - atleast 15 days each.
2. Electives in
super-speci'alities should
given only as part of major postings for
days in the two months.
be
15
3. In casualty
first call.
on
service the intern should
be
Post-Internship :
When a graduate after internship feels he needs reinforcement
in any particular area, he should be given an opportunity to
work for 2-3 months more after internship during which period
he would continue to get the same stipend as the interns and
this period could be included in the period of rural service.
An interesting feature that emerged from the sharing of
experiences was that all those who had participated in the
scheme
after completing 6 months - 1 year of
senior
housemanship fared better than those who went soon after
internship.
This is reflective of the lack of
skill
orientation in the present internship and the fact that in the
present system, as such one has to be an SHO before one gets
some opportunity for independent decision making.
Our recommendation is to make internship more skill oriented
but in the event of their being practical difficulties in
implementing
such a recommendation the
college
should
seriously consider allowing graduates to do a 6 month senior
housemanship before sending them to run rural hospitals
independently.
73
Refresher Courses :
Instead of a common refresher course every graduate working in
a rural hospital should be given upto 1 month posting in a
department/s of his choice during his service period in the
hospital according to the convenience of the doctor and the
hospital.
This would be somewhat similar to the electives for
the plantation medical officers that we hear the college
offers at present.
Future Career Prospects :
1. Post Graduation in. SJMC :
i. For selection to PG courses in SJMC absolute
preference should be given to SJMC graduates
who have undertaken the RBS Scheme.
ii. Extra weightage should be given to candidates
- for every extra year of service
from the statutory two years
done
apart
- for persons who have worked in remote
or areas of real need
areas
- for persons
hospitals
who have worked
in
TB/Leprosy
- for persons who are willing to continue to
work in rural areas after PG course. (Be may
be required to give another bond with the
rural hospital or with SJMCH).
If with the
rural hospital, then they should sponsor him
to the course.
2.
Postgraduation Centres :
CHAI can consider sponsoring him to other major
teaching hospitals like CMC Vellore and Ludhiana,
PGI Chandigarh for courses.
3- Jobs in Non-Scheme Hospitals :
CHAI could arrange to find him a job in
i. any
other
bigger member
hospital
completion of two years on the scheme;
after
any other member hospital after completion of
post-graduate courses.
In effect CHAI would
have to be actively involved with a career
guidance and placement service, trying to link
the availability of candidates to
hospital
situations
which would best
utilize
the
doctors' training/qualification and experience.
Newsletter :
i. This should be & monthly publication.
ii. Should refleet/review problems and needs of rural
areas/rural
hospital
practice/rural
hospital
personnel.
iii. Should serve as a two way communication.
iv. Participants during the placement should share
experiences, cases of interests and write articles
of relevance to rural hospital practice.
v. Doctors
who have completed placement
should
continue to write articles for the newsletter
sharing
their
perspective
with
the
newer
participants on the scheme.
A FOLLOW ILE £LAK
From the workshop itself including the discussions with a few
college staff and CHAI team and resource personnel some ideas for
follow up emerged.
1. A report documenting the main issues discussed
suggestions/recommendations made should be prepared.
and
the
2. This report should be circulated for information/comment to
i. all doctors on the rural placement scheme;
ii. all departments of SJMC/H;
iii. CHAI team and Executive Committee;
iv. CBCI Society for Medical Education;
v. all resource persons who could help with
follow up action.
evolving
3- A Committee weg formed Xpl take xm the matters specifically
related to medical education in St.John's and follow it up
with the staff council and management.
They would meet after
the report is made to consider follow up action.
t. A meeting of the staff council of SJMC/H would also be held
when two/three representatives of •the participants would
present the main findngs and suggestions directly to the
staf f.
5- The CHAI would initiate a process with SJMC management to set
up the Liaison office which would follow up on all
the
recommendations on the rural placement scheme itself as well
as the hospital policy issues.
This would be taken up for
discussion by introducing it as agenda for future meetings of
member hospitals as well as by initiating a dialogue on these
issues through the pages of Medical Service.
75
CONCLUSION
THE WORKSHOP hopefully was a beginning of a process.
It is but
relevant
that graduates of a medical college committed to the
objectives of producing professionals "dedicated in the service
of the country and especially the disadvantaged and the poor',
should come back after two years of service in rural areas to
give a frank and constructive feedback to their teachers about
the strengths and the weaknesses, the opportunities and threats
they faced in their own medical training and in the rural
placement scheme.
This report marks the beginning of this
process.
SOME ADDITIONAL U2IES
ISSUES QE CONCERN
:
The review undertaken by the pioneers of the scheme over two days
at SJMC resulted in a series of meaningful recommendations for
improvement of the scheme and the preparatory training given by
the college in the 5 1/2 years preceding it.
Taking an overview
of the entire discussion, the following emerge as important
issues of concern which the CBCI, CHAI and SJMC should study
seriously.
In the months/years ahead suitable measures to tackle
the problems should be evolved.
1. First and foremost is the growing commercialisation in the
ethos and practice of hospitals in this network.
This may be
primarily related to the problems of funds required for making
these hospitals self-supporting (especially in the absence of
continuing external aid).
In the light of the value system to
which these institutions are committed in principle,
this
trend is particularly disquieting.
This commercialisation is
resulting in an increase in unethical practices in patient
care,
unnecessary
investigations
and
hospitalisations,
irrational and over prescribing of drugs and increasing
inequalities in staff salaries and facilities.
This trend is
leading to an increasing option of care for the well-to-do and
paying patient to the detriment of the large majority of the
poor and needy patients.
This trend is complicated further by
a spirit of institutional competition.
The second important issue is the inadequacy of the training
particularly of our medical/nursing colleges in the light of
the growing needs and realities of the areas in which these
peripheral institutions are situated. We are not training
personnel to be specifically equipped to work effectively in
small
hospitals.
Our training is
highly
specialised,
technology oriented-based on curriculum that are geared to the
needs of large Western type urban hospitals.
The work in
peripheral rural hospital require independent decision making,
skill competency and a technically sound but innovative
creativity which will help one to modify/adapt the management
of the patient to the socio-economic and cultural realities of
the people in the rural areas. Preparation for this is sorely
lacking.
The cultural ethos of most of our institutions kills
rather than fosters the motivation/ski11s to work in areas of
disadvantage.
76
3. The third important area is the lack of involvement of the
doctors
and
the
hospitals
in
the
scheme
in
preventive/promotive rehabilitative or extension programmes in
the community.
In a few exceptions the doctors mentioned it
in passinc.
Mainly these programmes,
if and where they
existed were responsibilities of nurses rather than doctors.
The awareness that these programmes, wherever they may be
initiated
must move
beyond
distribution/welfare/charity
programmes to awareness buiIding/organisation/conscientization
programmes where people participate in
planning/decision
making/'organising programmes and see these as their rights,
was singularly absent.
This feature raises many questions
about the rural orientation of the medical college teaching,
the claims of the church institutions of the "preferential
options for the poor" and the understanding of
member
hospitals and dispensaries in the very concept of health and
their vocations.
t. The fourth important issue is the lack of sensitivity in our
institutions and the professionals working in them including
the young doctors to the social realities of inequality and
injustice
in the areas of work and even
within
the
institutions.
Most of the participants of the workshop were
quite affected by the increasing commercialisation and the
technical obsoleteness of the medical care in our hospitals
which was a very positive sign that they were thinking and
questioning, However, with few exceptions they were unaware of
the problems of the people and even the para medical hospital
staff.
None of them mentioned the people as such in their
sharing and the few that did had many negative and biased
ideas based on a myopic professional understanding of the
situation.
This was ..both reflective of the lack of out reach
programmes in most of the hospitals on the scheme thereby
doctors having very little contact with the people.
It was
also probably reflective
of the ethos of the training
institution in which they had been formed.
This lack of
sensitivity to social realities seems to pervade SJMC and the
leaders of the profession are so preoccupied with their own
salaries and benefits and commitment to private practice that
it may be an impossible task to expect them to transfer any
other type of commitment to the students under training.
These four issues should become causes of concern since they
question the relevance of health care and training provided under
the umbrella of a church.
We are convinced that through dialogue
and a spirit of committed introspection , all concerned in CBCI,
CHAI and SJMC will definitely identify means to tackle these
issues and initiate processes to take church health services of
the future in more relevant and people oriented directions.
Source: Edited
version of a cyclostyled
report
circulated by CHAI/SJMC/CHC to all concerned.
Recommendations on Rural Placement Scheme
itself and some policy issues relevant to the
hospitals selected for the scheme were also
deliberated upon but have been left out from
this version of this report which focusses
only on ’Medical Education’ issues.
77
APPENDIX XX
MEMORANDUM
ON. 1A HEALTH UNIVERSITY 'TO GOVERNMENT
11985.1
KARNATAKA
To
The Chairman and
Members of the Committee for
University of Health Sciences in Karnataka.
Dear Sirs,
We the undersigned are a group of people interested and involved
in
Community Health Action and Research, who
have
come
together recently to form a network to facilitate a greater
collective dimension in our efforts, to enquire into the health
problems and health priorities of the State and recommend policy
alternatives and offer critical feedback to health policy makers
and health team trainers in the State.
2. We encompass within our group, the disciplines of medicine,
nursing, public health, social sciences, nutrition, management,
social work, psychiatry, epidemiology, art,
communications and
journalism and related skills as well as derive our inspiration
from years of grass roots field experience and involvement in
health action through voluntary agencies and non-governmental
community based organisations.
3.
It is with this inter-disciplinary community oriented shared
perspective and concern that we offer the following ideas and
suggestions to you all, who have been requested by the Karnataka
Government to examine and report on the setting up of a
University' of Health Sciences in Karnataka.
II. At the outset we welcome the Committee's initiative to seek
the views of all those who are interested in this matter and
appreciate the chance for a participatory dialogue.
5. We believe that the situation of education of the health team
and particularly the medical education of the doctor has been
severely compromised in the State in the recent decade by --
a. falling of standards in medical education
by a dilution of requirements;
b.
caused
quantitative expansion at the cost of quality;
c. commercialisation of medical education by
growth of capitation fee oriented colleges;
the
d. generation of medical college growth on caste and
religious affiliations;
e. phenomenal commercialisation of medicine and
health service structure; and
the
f. politicisation
of
university ethos.
the
academic
bodies
and
78
Therefore, we believe that not only is there an urjent need but a
near crisis situation which the formation a University of Health
Sciences may seek to redress, re-orient and realign toward our
national and State priorities and stated seals of a secular,
socialist democracy,
and a society committed to rooting out
injustice and inequity.
6. However, we believe that a unique project such as this should
not just seek to halt the dilution of standards and provide a
framework of standardisation but also seek to commit itself to
certain long term goals of creative innovation along the goals
suggested by three national bodies in recent years.
(a) Firstly,
the grout fin Medical Education Al Support
Manpower set up by the Government of India (Srivastava
Report,
1975) has set before all medical educators the
challenge that there is need
"to design a system of education that is
rooted in the scientific method and
yet
profoundly influenced by the local health
problems and by the social,
cultural and
economic settings in which they arise"
and
followed
it up with a
series
recommendations of great consequence.
of
radical
(b) Secondly,
the ICMR/ICSSF. Health for All Study Group in
1981 has exhorted educators of health teams to prepare
members for a
"health care system which combines the best
elements in the tradition and culture of the
people with modern science and technology,
- integrating
promotive,
curative functions,
preventive
and
- democratic. decentralised and participatory,.
- oriented to the people.
- economical, and
- firmly rooted in the community and aiming at
involving the people in the provision of
services -they need-, and increasing their
capacity to solve their own problem."
(c) Thirdly,
the
Natip.n&l
categorically states that
Health
Policy
c£.
"the entire basis and approach towards medical
and health education at all levels should be
reviewed in terms of national needs
and
priorities and the curricular and training
programmes restructured to produce personnel
of various grades of skill and competence who
are
professionally equipped and
socially
motivated to effectively .deal with day to day
problems within the existing constraints.1'
79
In
line with these recommendations,
we see a
phenomenal
opportunity for our State to pioneer and meet the challenges of
producins more relevant health teams -- professionals
and
paramedics -- through the current move to set up a Health
Sciences University.
7- We are particularly heartened at the use of the term 'Health
Sciences’ and not ’Medical Sciences', since we see that true to
the comprehensive definition of health, the proposed University
should seek to ultimately brine under its jurisdiction not only
all the training institutions for doctors,
nurses,
pharmacists
and para-medicals but also the trainine institutions of othersystems of medicine so that through interactive
dialogue,
interdisciplinary teaching and an ethos of both respect and
openness 'to the rich diversity of Indian inheritance,
a truly
National System of Health Team Education can be generated with
great credit to our State.
8. We realise that the Committee cannot consider only lofty goals
and long term visions but must start considering the .project
proposal in the context of the present realities and compulsions
and state of medical education today.
Hence, we present three
sets of recommendations to the august committee:
I. Recommendations of improving medical education
standards by bringing together all the 18 medical
colleges and their teaching hospital under the
jurisdiction of the University.
II.
Recommendations
of
widening the
scope
and
jurisdiction of the University by involving all
other
health training institutions
of
both
allopathic and other systems of medicine.
III. Recommendations
of
radically
altering
the
curriculum through initial experimentation and
dialogue and pedagogical research from a long term
point of view.
RECOMMENDATIONS
i. Recpmnend&tions
in the State
±£> imp-rove and standardise medical
e.dlLC&t-ig.E
WE RECOMMEND that all medical colleges in the State both
private and government and their affiliated teaching hospitals
be brought under the purview of the proposed University of
Health Sciences with a view to --
(a) ensure that through regular inspection and dialogue,
all the affiliated institutions follow the minimum
requirements laid down by the Medical Council of
India (MCI) and upgraded by the MCI from time to
time.
(MCI recommendations are minimum requirements
and
hence
non-compliance
with
even
minimum
requirements is the first step to dilution of
standards)
80.
(b} ensure that no institution commercialises medical
education by charging capitation fees in any form
and
through
this
commercial
process
caters
predominantly to the needs outside the state, while
at the same time pressuring the government for tax
payer subsidy through grant-in-aid and use
of
government hospitals.
(c) ensure that the policy of allowing medical colleges
on caste/religion bias should be discontinued and
all those existing under such auspices should be
enabled to become more secular and cater
to
economically and socially disadvantaged through a
quota system in which academic merit should be final
within each quota.
(d) ensure that the existing
social/'rural
orientation
particularly --
MCI
of
recommendations on
medical
education
i. rural and urban field practice areas;
ii. interdisciplinary
teaching;
community
oriented
iii. community posting in pre-clinical/clinical
years;
iv. referral services complex and
of
district hospitals and
primary health centres;
affiliation
government
v. 6 months Community medicine posting in 1
1/2 years compulsory rotating internship
are implemented.
(e) ensure
that
the
anamolous
situations
and
disadvantage
that is arising from the present
policy
of
allotting
meritorious
government
candidates in private and unrecognised colleges is
prevented.
(f) ensure that all teachers of affiliated colleges
given the orientation courses recommended by
MCI:
i.
Training in teaching methodology focussing
on small group, interactivce,
experiential
and participatory methods;
ii.
Social
and community
orientation
priorities for health services.
are
the
and
(g) ensure that the Social Sciences inputs into medical
colleges particularly Preventive and Social Medicine
Departments is strengthened.
(h) ensure that training in teaching methodology
introduced into all post-graduate courses.
is
81
(i) ensure that there is serious implementation of
ROME propramme in which the total faculty of
medical collese should be involved.
the
the
In addition,
we believe that the Academic Council of the
proposed University should from time to time keep tab on all
the innovative ideas and methods of teaching that different
institutions affiliated to the University generate and that
all such ideas should be made known to other institutions to
emulate.
The university, while standardising minimum standards,
should
encourage a certain degree of creative autonomy within the
time
and other constraints of the existing
curriculum
structure so that more relevant curriculum innovations can
emerge to meet the overall goals of the University.
Recommendations Xs bring ill Health Training
under the University ' s .jurisdiction
WE
(a)
Institutions
RECOMMEND that
the University should bring under its jurisdiction
in a phased manner all training institutions in the
State.
at all levels of health service so that an
integrated and coordinated approach to
health
manpower
development
can
emerge.
These
institutions would include:
i. Nursing, Dental, Pharmacy colleges
ii. Rural Health & Family Planning Training
Centres and ANN training shcools
iii.
Colleges
of Indian and
other
allopathic systems of Medicine
non-
(b)
The
Academic
Council and Syndicate
of
the
University should have in its membership senior
educators from all these groups of colleges to
enhance the integrated effort.
(c)
In
the process of delinking health
training
institutions from the general universities,
care
should be taken that various other university’
disciplines
like
the
Behavioural
Sciences,
Management,
Social Work and so on are represented
on the Academic Council of the proposed University
this
being ensured by membersof
such
departments
invited
to
participate
in
the
deliberations of the Council.
(d)
As a first step towards greater dialogue and
acceptance of the role and contribution of each
member of the team and the different systems of
medicine, a plan of short orientation and 'bridge'
course should be evolved and introduced into the
curriculum of all courses; eg.. The doctors should
be given basic orientation in nursing,
other
systems of medicine and vice-versa.
82.
(e)
At a later staje,
a series of optional
and
elective courses should be built into the Health
University system to enable any member of health
team to supplement his knowledte and skills by
taking additional short certificate courses.
At a final state, para-medical and professional
traininc must be so linked up in a career ladder
pattern so that some experienced para-medicals
should be able to opt for and be supported through
professional courses.
III. Recommendations
io. radically alter the
curriculum
through
experimentation and. dialogue and pedagogical research.
There has already been a lot of thinking and brainstorming
on the need and some of the content of radical reform of
medical education.
The Srivastava Report warns that :
"no uesful purpose would be served by continuing an
endless debate on the content of these reforms.
What is needed most is the creation of a suitable
structure, with adequate administrative machinery
and funds at its disposal, and to charge it with
the responsibility of determining and implementing
a radical programme of reform in medical and health
education in the years ahead."
We believe that all the above recommendations are possible
given the political will and the administrative/financial
and technical safeguards built into the University of Health
Sciences Bill.
Re.se.sr.C-il Commission :
However, radical reform needs research and -exploration into
many other aspects of the existing system,
which have only
received lip sympathy till now.
WE RECOMMEND that
the Academic Council and Syndicate should constitute
an
interdisciplinary educational research commission
which
looks into each of these issues from a futuristic basis and
makes suitable recommendations to the Academic Council of
the proposed University after dialogue with MCI so that each
of these issues is considered and added to the re-orienting
process of existing efforts. These areas include -i. Research into teaching methods and examination/
evaluation methods;
ii. Gender bias in content of curriculum;
iii. Teaching in the vernacular medium;
85
iv. Conceptual and orcanisationl framework for
evolution of a National System of Medicine;
the
Link of educational effort with manpower
and career planning of existing manpower;
needs
vi. Role of Non-Governmental Organisations,
General
Practitioners and unaffiliated small peripheral
institutions in training programmes.
c. We believe that the role of the Directorate of Medical
Education needs to be continued only if the Committee believes
that the Academic Council and Syndicate of the propsed University
cannot handle all the functions that is presently carried out by
the Directorate.
Except for the liaison of the institutions
affiliated to the propsed University with the rest of the health
services we believe that most other functions can be taken over.
The Directorate,
if continued, will have more of a
liaison
rather than a directive role and in that sense will have a more
limited function.
In either case efforts must be made to
depoliticise this appointment and ensure that a holistic vision
and commitment to the goals of the University is given priority
over seniority and political compulsions.
This is actually even more true for all the appointments to
proposed university structure.
the
10. With reference to the fifth term of reference given to the
Committee,
we believe that the University should bring the
colleges and main’hospitals affiliated to the institutions under
its Jurisdiction as well as all the research institutions.
For
district hospitals,
primary health centres and urban health
centres that are affiliated to present teaching institutions,
a
more flexible policy may have to be evolved since to avoid a
region, a district, a primary health centre or a specific centre,
getting all the attention and support from training institutions,
it nay be necessary to rotate the affiliation over a period of
time so that all district hospitals, taluk level hospitals and
primary health centres are affiliated at some time of the other
thereby improving the quality of service and training and
continuing education of the centre/hospital staff.
11.
Finally we believe that if the Committee recommends the
setting up of a University of Health Sciences after examining all
the related, incidental and ancillary issues connected with the
proposal,
a larger dialogue should be initiated with all those
concerned about improving, re-orienting or making more relevant
the present pattern of health team training and professional
education in the State.
Our network would be willing to support this dialogue and
such forum set up by the Committee, and do more home work
provide more comprehensive and detailed recommendations on
ideas and views suggested in this memorandum.
any
and
the
84
12. While thankinc the Committee for this opportunity to ehare
our collective ideas about the proposed University, we sincerely
hope that the much needed radical reform that has been much
talked about in the country and in this State in the past,
now
finds
serious
consideration,
imaginative
leadership
and
sustained encouragement through your efforts.
Sub-Committee
on
Recommendations for University
Sciences, Karnataka.
of
for COMMUNITY HEALTH NETWORK (KARNATAKA)
* Ravi Narayan
* Thelma Narayan
* Sanjeev Kulkarni
* Shirdi Prasad Tekur
* Joseph Panackel
* K.Gopinathan
* G. Gururaj
Health
85
AFP£JiDZ?2 XXZ
Pros
and
Cons for an
'Alternative
Medical
College'
Three Crucial Questions
a.
is. the need Xc. start & xxsa
for this purocse?
What
medical
college/institution
1. Most insitutions who are now interested in re-orienting
Medical Education did not do adequate homework in
Planning the new strategy and so have ended up with
'pious' claim in the prospectus or at the most a few
years of experimentation followed by a status quo.
2. The experimentation has been somewhat 'ad-hoc' and often
in some disciplines only.
The whole medical college
multi-disciplinary
faculty as a team or even a core
team have usually not been involved.
The overall
content and value system is mostly of the established
system.
The older institutions have developed an
inertia,
resisting innovation either due to weaknesses in the
early
experiments
itself,
peer
group
pressure,
established values and focus of the existing system,
or
the social values of teachers and students and parents
and the governing board.
t. Most of the experimentation has been on evolution of
some new programmes; follow up of good ideas of some
faculty;
transplanting ideas tried out elsewhere in
other institutions sometimes out of context and so on. A
detailed
exercise
of identifying
needs,
setting
objectives, evolving teaching content and methodology as
a complete process has not been done.
5. The
new Medical College needs to evolve
a
new
institutional ethos and a critical faculty to relook at
established values, methodologies, concepts and so on.
This tradition can be built up as a new venture.
Changing these in an established college which has shown
'excellence'
or
'promise'
in
the
established
transplanted system is difficult.
6.
'Success' in the present paradigm of Medicine may itself
be
a 'barrier'
to exploration of an
alternative
paradigm.
7- All the existing medical colleges, even those who have
tried out some experiments have not questioned the basic
underlying
philosophy
and logic of
the
present
'westernised'
system.
Some
of
the
good
innovations/changes made have essentially been
by
B6
individual/'smali groups, but have never been accepted or
internalised by the system which sees all these as of
great threat to their orthodox
styles of functioning.
Perhaps it would be necessary to have a new and open
environment ,to dare to be self-critical and change
appropriately.
1. It is operationally easier, cost-effective and sensible
to incorporate these ideas into an existing institution
provided
a. a climate for innovation and change can
up,
be
built
b. a commitment to relate to social need is ensured
(because there are many innovations unrelated to
social need) .
2. It will be more acceptable to all concerned when
established institutions change tracks with changing
circumstances
rather than if the
institution
is
completely new, lacks est&blished credibility and as a
result can get marginalised and ignored. It will also
prove that existing institutions can and do change which
ultimately will be necessary for thereto be a major
impact in training doctors for India's social needs.
A
de novo college can always be viewed as an experiment
with unusual factors and hence not replicable.
3. If the alternative curriculum is a response to a deeper
understanding of social needs and the social milieu,
then there is no reason why an existing team of a
college cannot support the alternative as long as they
get a deep and thorough orientation to the evolving
concepts and process.
L. Those who have experienced and participated in the
present
track know its pitfalls,
limitations
and
difficulties
if they have been serious in
their
endeavour.
They are more likely to appreciate and
sustain a gradually evolving alternative process than a
set of
'idealists' who evolve an ideal curriculum on
paper but do not have the experience to sustain or
operationalise it.
5. India already has a surfeit of medical colleges, many of
which were started with social objectives as well.
Adding one more may be unnecessary.
87
3.
Whv should .that ha Ixx the Voiuntary/NGO/Mission sector ?
(Voluntary/Mission sectors are not synonymous.
A secular
effort initiated by 'Missions' may prove more fruitful)
1. There is
possibility of greater adaptability
and
flexibility to changing circumstances as compared to the
government sector.
2. Minority insitutions committed to a ’value system'
especially the 'Mission sector' have shown a continued
commitment of purpose and responsiveness which supports
innovation and excellence.
3. Minority Right provides greater flexibility for student
and
staff
selection which could
become
crucial
components of an alternative experiment atleast at the
experimental stage.
u. The alternative curriculum derives sustenance from a
social commitment and vision of the alternative team.
This is more likely to be sustained in a voluntary and
or Mission sector since such congruence between social
vision of the endeavour and the faith and mission values
of the insitutions are possible. The group could take
positive steps to actively interact with the mainstream
*■_, through
participation
in
professional
associations/exchange programmes and networks.
Against
1. The Government sector may not take it seriously and so
may not be affected by it.
There is a tendency for
Minority
institutions to be marginalised
by
the
establishment especially if they push the minority label
too much.
2. Minority institutions themselves have tended to stay
aloof
from interaction/confronting
the
government
system.
They often fail to fit into
mainstream
requirements and are prone to getting walled off from
national influence many of which can also be positive
stimulus for developing into appropriate centres for
education.
e.g.,
it is not unusual
for
Mission
institutions to see their graduates as being destined to
work in Mission
hospitals and not as leaven in the
general governmental medical system.
3. The so called voluntary / Mission sector is today being
fast overtaken by the Private Corporate sector as well
as being forced to change value systems due to the
'market forces'.
So that the label is not a sufficient
pre-condition for serious innovation.
Should Xhfi. Effort
io. Produce :
(a) an 'appropriate’ medical graduate?
(b) to take the present medica' graduates and give
'appropriate' PG training?
them
1. Most of the existing
graduates are not
socially
oriented or 'professionally competent’
to work
in
Primary Health Care of Community Practice.
There is
need to change the system to produce
appropriate
graduates from all the existing institutions even if the
start is with a few.
2. The existing system has been critically analysed and
found to 'block' the development of certain skills that
are required in the Primary Health Care situation,
so
change in graduate education is inevitable.
3- Certain fundamental attitudes and principles of problem
based learning,
self learning,
field based learning
etc., would enhance the existing skill of medical
college products even if they predominantly choose as at
present,
secondary and tertiary care centres as career
options.
The appropriate transformation of graduate
training is therefore inevitable.
1. Many of the doctors graduating from the
existing
colleges are 'misfits' as far as national needs and
priorities.
They can only land up in the growing urban
private profit-oriented sector.
If 'Health for All' has
to be a reality than many need retraining/continuing
education to refit them towards newer Job opportunities.
An IAS type orientation training post-selection for
government doctors and pre posting is crucial.
This
could be at two levels:
I.
All doctors selected by UPSC and State Boards
should be given a reorientation course, which
is substantial in skill / knowledge but not
necessarily a PG level course.
II.
All PHC based doctors could get an inservice
continuing education through distance learning
modules as well as
regular contact seminar
leading
to a PG qualification.
With
the
era of open university being established in
India, this needs to be explored actively.
B9
III.
Revamping existing DPR and ND (FSM) training
an equally crucial task.
is
This question is not really an either or alternative.
Any alternative experiment whether in an existing or a
new
institution should simultaneously
promote
exploration / experiment at both levels. The problems
encountered by PG training of existing graduates would
cross
fertilize the
evolution of the
graduate
training itself !
Appropriate PG
training would
help in tiding over the existing crisis of a ’glut' of
'Misfits' and also advance the knowledge
inputs
required for innovation at other levels
!
!
!
!
!
!
!
All
those
interested
in
launching
an
alternative
experiment are requested
to
reflect on the above 'pros' and
'cons' collectively and make
their own group/institutional
decision.
Position: 477 (8 views)