Overcoming the Health Care Crisis: Bold Reforms in Medical Education and Health Service Systems
Item
- Title
- Overcoming the Health Care Crisis: Bold Reforms in Medical Education and Health Service Systems
- Creator
- Ritu Priya
- Date
- 2006
- Description
- A Note Prepared for the XIth Five Year Plan Task Force on ‘Planning for Human Resources in the Health Sector’, 2006
- extracted text
-
Overcoming the Health Care Crisis:
Bold Reforms in Medical Education
and Health Service Systems
A Note Prepared for the XIth Five Year Plan Task Force on
‘Planning for Human Resources in the Health Sector’, 2006
Strengthening public health as a discipline through expansion ofpublic health education
is a widely recognized need, as is the constituting of an Indian Public Health Cadre
(Kolkata Declaration, SEARO-WHO; D.Banerji; N.S.Deodhar). The MFC Anthology
'Medical Education Re-Examined' (1991) presents the earlier, discussion in MFC on
factors shaping the products of medical education. It draws links between the students'
social background and thereby admission policies; the curriculum, teaching and
evaluation methods they are subjected to; and the service system they finally go to work
in.
This note, written for discussion in the 'Task Force bn
Planning for Human Resources in the Health Sector’ for the XI Five Year Plan, places
Public Health Education (PHE) within the context of the overall health service system on
one hand and medical education on the other. It presents an outline for structural
changes, not as a final blueprint for action but to generate discussion in the concrete for
the present and future development of the health service system and its humanpower. It
proposes one possible perspective for expanding public health education in India, -and is
therefore being circulated as background material for discussion at the MFC Annual
Meet-RP
The Crisis and the Challenge
A crisis in our country’s health services system is growing increasingly evident. The
middle class and poor experience it as absence of affordable, effective and trustworthy
services with stark shortcomings in the functioning of health care institutions and
professionals. Doctors experience it as professional insecurity, since specialization has
come to be perceived as necessary while opportunities are inadequate. Sub-standard
work conditions in both public and private sector further frustrate them. This is not an
exclusively Indian crisis. It is being experienced world-wide, albeit with variation across
regions and countries. In India a body of official committee reports and health systems
research repeatedly points to factors responsible for the crisis, among which is the urban
and elite bias of medical education. Over the years proposed solutions to rectify this
have been half-heartedly implemented.
In this note we argue for a strong commitment by the senior political and administrative
leadership to deal with the crisis. We are proposing comprehensive reforms aiming for
appropriate human resource development and enhanced performance in the health
services field. This calls for planning with bold and long-term vision. Hereby we mean to
enhance the discussions on urgently needed reforms in the health care sector and the
corresponding human resource requirements. After briefly identifying the major problem
areas as we see them, we outline a broad framework and focus on some concrete
measures towards long-term restructuring that can be initiated under the Eleventh Five
Year Plan.
Perspective of the Proposed Reforms - the Problem Areas
1
Major shortcomings identified in health personnel over the years are:
i)
social alienation from people to whom they are providing services,
and
ii)
lack of a sense of responsibility towards patients and communities.
Systemic factors that require rectification include:
1.
Inadequate Professional Education: it neither orients nor motivates
doctors to face the vulnerable sections' needs; it reflects in elite social
behaviour, career choices, and technical approaches to health
problems.
2.
Overcrowded & Ill-Maintained Work conditions in Public Institutions:
they do not favour establishment of norms for good medical practice.
3.
Over-emphasis on Specialization: practice for high-profit is justified
by high investments of time/money on education and specialized
infrastructure; malpractices (over-prescription of tests, unnecessary
surgeries, and so on) become the norm.
4.
Absence of Monitoring and Public Accountability , there is no
monitoring of professional performance in either public.or private
health services sector.
Clearly, a multi-pronged and comprehensive approach is necessary to deal with this all- •
round crisis. It needs to simultaneously address equity and quality issues relating to
both service delivery and human resource development which are inter-twined. If
implementation of the NRHM is to succeed in the Eleventh FYP, all health personnel will
need to undergo a shift in orientation and attitude both through training and through re
oriented administration of the services. To foster re-orientation in medical education, the
work-culture in training hospitals (where under-graduates and post-graduates learn) will
need to encourage norms of good practice. Contradictions will have to be faced. For
instance, doctors working in the private sector may imbibe patient-friendly behaviour, but
they may also learn to protect profits at patients’ expense. On the other hand, public
sector work-norms are less commercial and more cooperative, but they are also more
bureaucratic. Developing mechanisms to combine the best of both is the challenge.
Systemic restructuring is therefore necessary. Administration and management
structures and measures that promote appropriate and locally responsive work-culture
should supplement all efforts at human resources development. For the Health
personnel to perform well according to their education and training, the professionals
must be allowed decision-making powers at various levels for local resource allocation,
personnel deployment and priority-setting. At the same time, recognition for good
performance in providing routine and responsible services has to be built into
administrative structures and processes. Criteria for assessing quality of performance
and mechanisms for appropriate deployment need to be evolved and implemented.. For
all levels of personnel, mechanisms for incrementally upgrading skills are required. We
must insure accountability to communities and society and produce health personnel and
norms of medical practice that fit our context.
For facilitating such system-wide changes, we are proposing the creation of an Indian
Public Health Service on par with the Indian Administrative Service (IAS). To guide and
2
monitor the transformation process, we propose that a ‘Steering Body for Health
Systems and Human Resource Development’ be set up within the Directorate General of
Health Services..
The Feasibility and Benefits of the Proposed Restructuring
In India at present there are 229 MCl-recognized medical colleges. Of them 125 are
government institutions, which generally have a greater number of students. Thus, if the
Government at the Centre and the State Governments gather the political will to improve
medical education as called for, much can be done. By international performance
standards, India is doing fairly well as doctors and nurses produced in our country are in
demand and perform well in other countries. However efforts at adapting medical
education to rural Indian settings have not taken off, starting from the Sokhey Committee
and Bhore Committee recommendations in the 1940s to the POME Programme in the
early 1980s. Why will another such proposal succeed now?\s a good question.
At this point in time there appear to be- greater possibilities of change for several
reasons. One is a shift in conditions and context. Earlier proposals came-wherrthe
~
number of doctors and secondary hospital care facilities in the country were inadequate,
when modern medicine was unquestioned as the ultimate science for health care, and
when western state-of-the-art medical care was taken as ‘quality care'.. So medical
education and doctors tended to cluster around the tertiary hospitals and specialists in
clinical subjects became the leaders of the profession. Today the situation has changed.
On the one hand, a r'nassive public and private sector infrastructure has come up in most
parts of the country and there is 1 'doctor per 2000,persons. People are increasingly
resorting to modern medical care. On the other hand, at tire global level there is a
growing recognition of the limitations and unsustainability of the western industrial model
of ‘healthcare’.
Medical professionals are a disgruntled lot, too. Currently, with poor working conditions
and unexciting assignments, doctors are not attracted to the public sector. Yet the
drawbacks in the private sector (competition and commercial considerations often
winning over professional ones) restrict job satisfaction there as well. Increasing
numbers of doctors joining the IAS or going into non-medical business is evidence of
professional dissatisfaction. Therefore, significant support for the bold initiative that this
proposal entails may come from enthused doctors.
Thirdly, in this time of drastic economic reforms and political reformations, it appears that
such measures may make headway, provided active support comes from the highest
levels. Demonstrable forms of low-cost effective health care in our country may even
provide lessons for international health services and humanpower development. The
international set of needs and conditions are changing as well. Saturation of medical
and nursing professionals and limitations on immigration in the industrialized west is
becoming offset by a growing demand for public health workers in the Middle East,
Central Asia and Africa. In order to produce humanpower suitable for ‘export’ to these
parts, developing skills to suit developing country contexts will be meaningful.
An HRD Plan for Indian Health Services:
A Framework
A comprehensive framework for restructuring the Health Services and HRD Systems is
proposed. Within the essential focus being on meeting Primary Health Care goals, it
gives primacy to three outcomes:
3
i)
Building up low-cost rural/urban health care settings as the hub of medical
education,
")
Changing the restricting mindset that favours 'specialists' and hi-tech
solutions, and
iii)
Developing strong links between primary, secondary and tertiary health
care levels.
Primary Health Care includes health-sustaining measures at community level, first-level
diagnosis and treatment (first contact care) and appropriate referral. Its development is
the most critical ‘felt need'. At present, in fact, various 'alternative' systems unofficially
function to meet the need, from traditional folk healing practices to ayurveda,
homeopathy unani, siddha, yoga, to ‘allopathy’ in the hands of private practitioners,
informal and formal, alongside the Government institutional set-up. Lack of access to
effective and affordable first level medical care leads to greater resort to the secondary
and tertiary levels and creates an unnecessary overload in hospitals. Clearly, there is
need for strengthening each link across thi.s..continuu.m.of care; .from home-care to a ... - ■
team of doctor-supported community-level (PHC) personnel to secondary and then
tertiary level hospitals and research institutions. Professionals and para-professionals in
the AYUSH streams need to be integrated into this overall schema.
.
Health services system development must define the rational role of each type and level
of health care personnel, and HRD-must-givedueconsiderationto-the-approprtate-set-of —
knowledge and skills required by each. Inculcation of 'cooperative spirit’ must be part
and parcel of the'pedagogy, so that health care providers grow to act in the best interest
of people, facilitating optimal care at all levels and by other providers as well as
themselves.
Central to reorientation of the health care system is changing the mindset of doctors
trained in ‘modern’ western medicine, since they are the leaders in the Health arena. But
equally important are:
a)
Increasing the numbers of nurses and paramedical personnel to meet
shortfalls, and
b)
Giving them a similar reorientation as the medical professionals,
c)
Building up cooperation and responsible team functioning ,
d)
Strengthening the part of ‘AYUSH’ and its practitioners in the health
services, and
e)
Developing comprehensive health care practices across the health
systems.
Categories of Health Services Personnel
We are defining the Indian Health Services Sector to include all public (Government),
private and non-governmental I non-commercial institutions concerned with provision of
healthcare in India. We have re-considered the conventionally used categories of health
personnel in the changed health services context. The categories used here are based
on the major tasks required of them in the health sector (see the Box, next page).
4
Categories of Health Services Personnel
(Re-structured in the Current Context of the Indian Health Services)
1.
2.
Basic/Primary Health Care (Preventive & Curative)
•
TBAs (dais), Other Folk Practitioners (bone-setters, herbalists, etc.)
•
Community Health Workers (CHW / ASHA)
•
Paramedics (MPW, ANM, HA, PHN, LHV)
•
Nurses (Staff, PHN)
•
•
Allopathic Physicians, (MBBS - MO, GP, FP)
AYUSH Physicians (BAMS, BHMS etc.)
•
Non-physician AYUSH Practitioners (Yoga, etc.)
•
RMP ‘Doctors' (non-MBBS, in communities)
•
Health Team Managers (doctors, non-doctors)
• Specialised Physicians and Clinical Researchers
•
Clinical Specialists, including Dentists and Super-specialists
•
. Para-Clinical Specialists (Pathologists, Microbiologists, Radiologists,
etc.)
3.
4.
•
Specialist Nurses^SurgeryTPublic Health, etc.)... Etc.
.•
Specialised AYUSH Physicians and Researchers
Medical Care Support Personnel
•
Pharmacists
•
Laboratory Technicians
•
Physiotherapists... Etc.
Public Health Specialists and Researchers
•
•
5.
6.
Public Health Management Specialists (at secondary & tertiary levels)
Interdisciplinary Health Systems Researchers
(Bio-Medicine-Epidemiology-Social Sciences-Management)
Epidemiologists & Social Scientists in Health Area
Legal Experts in Regulation of Professional Services and Education
(Public Health & Law, Industry & Law, Medical and Health Ethics)
Public Health Support Personnel
•
Sanitary Inspectors
•
Entomologists
•
Laboratory Technicians
•
Biostatisticians... Etc.
Research & Teaching in Non-Clinical & Bio-Medical Subjects
Non-Clinical Subjects linked to Medical Colleges (including AYUSH
Systems)
(anatomy, physiology, histopathology, pharmacology, immunology, etc.)
5
Non-Clinical Subjects in University Departments and Research
Institutes
(Biochemistry, Chemical engineering, Genetics, Biotechnology,
Bioinformatics, etc.)
Note: There will be overlap between research and teaching of these
subjects
in medical colleges, university departments and research institutions.
Strengthening the Human Resources (Health)
Planning for the optimal development of categories of health personnel requires the
Health Ministry to take initiative in medical and para-medical education and training,
areas under its purview. In this it also needs to coordinate with Departments in other
Ministries, such as Education, Bio-technology and so on, for developing appropriate
training', services and research agendas. For the Health ministry itself, some urgent
measures to face the present crisis are discussed below:
A. Assessing Need and Defining Quality of Health Care (Personnel & Services)
B. Re-Orienting Medical Education to Meet Low-Cost Health Care Needs
C. Appropriate Development of Health Care within the AYUSH Systems
A. Assessing Need and Defining Quality of Health Care (Personnel & Services)
Measures to quantify the need for all categories of health personnel in public, private and
non-governmental non-commercial institutions, for the purpose of creating corresponding
teaching and training capacities, are as follows:
Estimation of the requirement for specialised Health personnel has to be
based on the real needs of the whole system. The numbers projected for
immigration should be added, since otherwise planning will lead to shortages
in the services in India.
•
This exercise is to be undertaken with the best existing database. Several
figures will have to be rough estimates, but even that will be worthwhile.
Quality criteria for each category of personnel need to be laid down based on technical
requirements, effectiveness in the social context, and affordability. For instance:
For doctors, good medical knowledge, ability to give effective treatment at
low cost, empathy, understanding of urban/rural social dynamics,
communication skills, team-functioning and ethics, and inter-sectoral
coordination should be important criteria.
For para-medicals, appropriate knowledge/skills, other qualities (as for
doctors), team-work skills, ability to debate issues and input in decision
making.
At Primary Health Care Level
6
At the primary level, the need is for a ‘community physician’ with the technical expertise
of a family doctor, capable of early diagnosis and treatment of the majority of health
problems. She or he needs to listen and advise competently, allaying fears and
anxieties; to have an understanding of public health issues, and the ability to lead a team
of community level health workers if needed. An order of intellectual input and
reasonable grasp is required to meet analytical demands, as clinical diagnosis is to be
made with basic testing facilities and optimal medical intervention is to be determined. A
willingness and ability to co-operate with other systems of healing for reducing ill-health
has to be cultivated. Such doctors must themselves demonstrate the best quality, as
they create a base for health and health care.
Increasing the number of doctors who will act as generalist family physicians and
community health team leaders is the need of the hour. Since such 'generalist' work is
as intense and demanding as that required of specialists, equity in status and payment
needs to be established. At this primary level, good performance by doctors demands
that they interact with people and gain familiarity with their communities on an extended- ,
term basis. Hence, the policies of arbitrary transfers and short-term contractual hiring of
doctors will have to be re-examined. For generalist doctors, if their status and
performance quality is equated with that of specialists, then the leadership role, work
satisfaction and quality of life that they can achieve will become attractions. Their role as
teachers of under-graduate medical students (as discussed further on) can give added
career satisfaction. Moreover, these doctors would henceforward be involved in health
planning and policy-making. Considering their social role, those ‘high achievers' among
who wish to go for Public Health specialisation might be sponsored. Naturally, these
roles would include qualified physicians of the AYUSH systems on par with MBBS '
qualified physicians.
All in all, creating a cadre of Indian Public Health Service will consolidate the experience
of such doctors and use it for health sector planning.
At Secondary and Tertiary Health Care Levels
Secondary level health care at District level again requires a large number of general
practitioners. But here they work in consultation or in referral relationships with experts
in the basic specialities (surgery, gynaecology & obstetrics, paediatrics, ENT,
ophthalmology, psychiatry, dentistry, geriatrics, and so on).
At the tertiary care level, specialists and super-specialists are in charge. These
physicians have greater expertise in a focused area of the human body or portion of the
disease spectrum. Therefore generalist doctors, whose professional focus is on patients
as whole persons in family and social contexts, can call upon them to deal with special
medical problems. Their status should arise from demonstrated competence in specific
fields, and as clinicians at both secondary and tertiary levels. Additionally, they may be
researchers and educators.
B. Re-Orienting Medical Education to Meet Low-Cost Health Care Needs
Given the framework of health humanpower needs of both rural and urban populations,
and the poor and middle class in both settings, the priority is to re-orient all medical
professionals to provide appropriate quality low-cost health care. Since doctors are
leaders in the health sector, re-orientation of other health personnel will follow.
7
First, let us briefly review some of the measures tried in the past decades to ‘reorient’
medical education and produce basic doctors in order to pose fresh options:
<)
Making service in rural areas mandatory for medical graduation or before
applying for postgraduate courses has not worked. Not only have most
students resented these postings, but it has also expected fresh graduates to
perform competently on their own at the rural level after having been trained
in tertiary hospitals.
ii)
The category of 'licentiate doctors’ trained in a three-year course is
proposed to be resurrected. It may have been meaningful when there was a
shortage of medical colleges and doctors. Today no such shortages exist, so
it would be better to re-orient medical graduates rather than re-create this
category. However, a large number of unqualified (non-degree-holder)
'doctors’ are providing medical care in poor rural and urban communities. It is
a reasonable option to evaluate and upgrade their knowledge and skills. Still,
their function in providing basic health care must be viewed as additional and
--net-as-a-substitute to the public sector.
.
■
What we are suggesting now is not a piecemeal solution, but rather a whole restructuring
■ of medical education and of the public health cadre simultaneously. We are suggesting
a direction for initiating deliberations in various fora. The main foreseen spheres of
action are:
(I)
Intake for medical education, with heed to the social base of students
(II)
Appropriate restructuring medical colleges, curricula and teaching
methods
(HI)
Improved functioning of teaching hospitals and all levels of health care
services.
(IV)
Strengthening of regulatory mechanisms for health care providers, and
(V)
Creation of an Indian Public Health Services cadre.
I. Intake for medical education
Dealing with the social alienation of doctors must relate to their social base becoming
representative of the populations that they serve. Measures for ensuring this are to be
taken at the time of student intake into medical colleges, and this is possible in the
following ways:
1.
Reservations for Disadvantaged Student Categories:
For SC and ST students, reservations may continue as such.
For OBC students, ‘backwardness points’ on the lines suggested by
Deshpande & Yadavl[1] can be applied (for admissions to be based on
1 [1] Satish Deshpande & Yogendra Yadav, ‘Reservation - An Alternative Proposal', The Hindu,
23rd May, 2006.
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individual merit plus social background), similar to what is already in use at
JNU for several years.
2.
Abolition of capitation fees in medical colleges:
Colleges should have other ways open to them for raising the funds they
need.
3.
Professional Up-gradation through Scholarships/Sponsorships:
Committed, competent lower-level health personnel (medical, nursing, etc.)
may sponsored for professional enhancement, enriching the academic
environment with their presence. Not only will this be an incentive for
performance, it will also create a pool of professionals with rich grass-roots
experience.
4.
Preference to Student Sponsorships from CBOs & Pancyayats:
Such medical and nursing students would be committed to returning to their
communities for later work.
11. & III. Re-structuring Medical Education for Professional Re-orientation &
Strengthening all levels of the Primary Health Care system
That current medical education is biased towards urban culture and high technology is
well recognised. Furthermore, teaching is rigidly text-book and lecture based. Clinical
skills are taught at bedsides in crowded tertiary hospitals, which fail to provide adequate
social and managerial skills or instill patient-friendly attitudes. The knowledge base that
is imparted lacks a public health orientation informed by people’s perspectives and the
social determinants of health.
To rectify these great shortcomings, two broad structural measures are being proposed:
i)
Move under-graduate medical teaching away from cities/tertiary hospitals,
and
ii)
Revamp the medical curriculum and teaching methodology appropriately.
Moving under-graduate medical teaching away from cities and tertiary hospitals
As oft-stated, clinical exposure needs to be imparted in appropriate settings. Since we
envision the majority of under-graduates becoming general practitioners and community
health team leaders, their education and training should take place at secondary-hospital
level with strong links to the primary level. This would mean re-setting the standards for
hospitals attached to medical colleges with regard to number of beds, etc. For public
sector teaching institutions, the senior teachers will be doctors at District hospitals; their
numbers will have to be increased to deal with the added workload.
Thus, the logical aim is simultaneously towards re-orienting medical education, bringing
specialists to District Hospitals and CHCs, and strengthening secondary and primary
infrastructure and functioning. The implications are that
All undergraduate teaching and technical training will take place at
secondary and primary level institutions.
9
Post-graduate teaching will be at secondary and tertiary hospital levels, with
periods of posting in rural and underserved urban areas.
•
A Public Health specialist will be placed at District level for consultation with
all levels of health personnel in epidemiological analysis and health system
planning. This job will include orienting clinicians, including the teachers of
clinical subjects, on the current and local public health issues.
While post-graduate and super-specialist teaching will happen at tertiary hospitals, post
graduate students of clinical subjects would serve for periods at the secondary hospitals
and visit primary level institutions on a rotational basis. They may bring in fresh ideas
and information of scientific advances to be considered by the teaching faculty for fitness
in local contexts.
Since existing training schools for paramedical personnel are largely placed at District
level, the location of medical education there will enhance the opportunity of team
training. The PSM course for medical under-graduates may well include bringing the
various health personnel categories together for practical experience of team
functioning.
Revamping the medical curriculum and teaching methods
Some measures towards making medical education problem-oriented, community-based
and informed by the social determinants would be:
■
. '
■
A comprehensive review of existing curricu-lum, textbooks ano teaching
methods:
This would be followed by text-book writing geared for Indian contexts by
teacher-practitioners with extensive work experience under Indian conditions.
For this, good teachers in each subject would be identified and their
interaction with the system facilitated to improve the quality of pedagogy.
Guidelines for medical teaching would be prepared, with special attention to
strengthening of public health teaching.
Tailoring of social science teaching for doctors to understand their social
role:
This would be an important component of medical education, so that doctors
grasp the social determinants and dynamics of health with regard to what is
expected of them.
Skill-building in critical analysis towards appropriate solutions:
This is important so that the doctors are able to work out optimal solutions in
diverse contexts and insure that inappropriate universal solutions do not
remain in practice.
Quality regulation and innovation in teaching institutions
Teaching institutions are to be strengthened according to defined criteria for
teaching quality and encouraged to innovate appropriately.
The professionals who come out of this kind of educational process will be familiar with
and sensitive to the conditions of the majority in this country and are thus likely to.
10
develop norms more of practice suited to them, whether they work in the public or the
private sector.
Monetary and non-monetary supports will be needed. Revamping could be initiated in
the Eleventh Plan.
IV. Building Regulatory and Accountability Systems
Progressive principles of personnel management need to be applied to change the work
culture and stimulate professional responsibility. Both administrative controls and
encouragement for good performance are essential. There must be transparent rules for
transfers, promotions, selection for higher education etc. and limitation of political
pressure to flaunt these rules. The word has to come from the PMO and Health Ministry
downwards.
Formal incorporation of community monitoring mechanisms into the health services
system is called for. Besides the panchayati raj institutions (PRI), some other structures
for social audit have been suggested by various people. This needs to be decided upon
after ca'refuf consideration and consultation, and seriousness about it has to emanate
from the higher Government levels as well as from civil society.
The Medical Council of India is already under review. Aside from re-structuring, it needs
a person of high moral and professional standing to be nominated as its head, perhaps
by the President of India. The MCI has to exercise its authority freely and fully for
ensuring maintenance of standards and quality. It must encourage innovation in
teaching, rather than stifle new initiatives.
Besides the external regulatory measures, professional accountability mechanisms are
something that professionals will themselves have to get serious about. Unless they
create self-evaluation and self-regulation structures they will be only technicians and
commercial entrepreneurs. Professional associations such as the IMA, IAP, FOGSI, etc.
would do well to deliberate on such issues within their membership.
V. Creation of an Indian Public Health Service Cadre
From among the generalist medical officers and health team leaders performing at the
peripheral level, some should be supported for public health specialization and move up
to play data analysis and planning roles. The service would create public health analysts
and planners with backgrounds of experience in rural and other low-resource conditions.
It will also enable professional mobility from primary to secondary-level service delivery
and to analysis, policy formulation and planning positions, from the Block and District to
State and National levels.
C. Development of AYUSH Systems and Human Resources
India has the advantage of having a number of health and healing systems in operation
for generations and even millennia. However, they have not developed or kept pace with
the modern western or ‘allopathic’ system which is dominant in both medicine and public
health fields. Health care providers of the AYUSH systems currently studying or
employed within and outside the public health services should be encouraged to
strengthen their respective science and practice. Some suggestions are:
11
vii) Setting up of a Core Committee for Dialogue Across Health and Healing
Systems.
Thus, reorientation of the health providers and service systems with an appropriate,
futuristic vision is an urgent and crying need for our health and wellbeing. The health
care crisis afflicting all sections of the Indian people and the crisis being experienced by
the health care providers calls for a major initiative well beyond the significant measures
that are already on the anvil-increasing the financial outlays to 2-3% and increasing the
infrastructure and number of personnel. How can we all come together to rise up to the
•challenge?
♦
t
[Acknowledgements: This note has drawn on reading of the several committee reports
of 'the past and available writings ofpublic health analysts. It has gained from
interactions with colleagues at the Centre of Social Medicine & Community Health, JNU
and the Medico Friend Circle. Special inputs by Drs. 7.' Qa'deer, C. Sathya'mala and Mira
Sadgopa! are gratefully acknowledged. This does not imply agreement on all issues in
the note. The author alone is bears the onus for its shortcomings.]
Ritu Priya.' MBBS, PhD
■ Associate Professor...
____ _________________________________________
Centre ofSocial Medicine & Community Health
Jawaharlal Nehru University
New Delhi-11C067
Phone: 011-26704420 (o), 26102638®, 9313350186 (m).
Email: ritupriya@vsnl.com
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