The following is the concluding statement issued by the National Conference on Health Professions Education 2011 held at Vellore on September 16 and 17, under the aegis of the Medical Education Unit of the Christian Medical College. The purpose of the conference was to bring together policy makers, academic institutions and health care providers to build and strengthen the linkages between health professions education and health care needs. The conference also aims to develop the capacity of health professionals in India to adjust curricular strategies and equip them to meet the health care needs of the population.
Today we are facing widening disparities in India in health status and access to basic health care. Catastrophic health expenditure is causing significant indebtedness. There is acute health manpower shortage, particularly in rural areas. In this context, the Conference raised the question: To what extent is medical education contributing to this crisis and is responsible for addressing it? While this Conference was on education in all the health professions, because of the large representation from medical faculty, there was a particular focus on the MBBS course. However the underlying principle of social accountability applies to all the health professions and our analysis and recommendations may apply, as appropriate, to health professions education in general.
Many of the factors contributing to this crisis are related to the present medical education system. The growth of medical colleges has been predominantly in the private sector and in a few states. Medical education does not prepare the graduate to function effectively in areas of need. Students who have paid high fees for private medical education prefer to pursue careers where they are able to regain their investment. As a result, there is the problem of wide scale foreign migration of medical graduates. Without the benefit of strong motivation imparted in their formative years, doctors are not inclined to work in rural locations and in difficult circumstances charecterised by lack of adequate remuneration, difficulties in school education for children and academic and social isolation. Medical colleges are not linked to and responsible for the health system (at the district and sub-district level) and for the health of a community in a geographical area. Thus, responsibility for the health of the community is not manifestly linked with medical education.
The participants of the Conference felt that the medical education community, including the medical colleges and their faculty, the Medical Council of India, and the Ministries of Health and Family Welfare and Human Resources, need to take responsibility for ensuring that medical education is socially accountable and aligns itself consciously towards improving health and health care provision for the people of India. This linkage between medical education and addressing health care needs is referred to as ‘social accountability of medical education”.
Based on the discussions and deliberation of the conference, the participants recommend the following steps to ensure social accountability of medical education.
Recommendations for medical colleges
1. All medical colleges should have formal linkages (or be affiliated) with district hospitals, taluk hospitals or other community hospitals for supporting clinical service and training. The medical college should also be responsible for health services of a defined population or community including tribal/underserved areas in its vicinity.
2. All general specialties involved in the MBBS course should be involved in the clinical service and training at the primary and secondary level.
3. The MBBS course should have multiple structured experiences within the community distributed throughout the training.
4. All MBBS students should have a significant live-in experience within the community in the I MBBS as part of the early clinical exposure so as to understand the community dynamics and the social determinants of health.
5. MBBS students should receive practical clinical training through clerkship/student doctor model in a graded manner towards developing clinical skills and competence in the management of common diseases with emphasis on those prevalent in the community.
6. Part of the clinical training in MBBS should occur at the primary and secondary level with involvement of faculty from general specialties. A block posting of clinical training of suitable duration (suggested 12 weeks) in III year at primary and secondary level in Medicine, Surgery, Paediatrics, Obstetrics and Gynaecology and Family Medicine is suggested.
7. Each MBBS student should follow up at least one family from the community service area, throughout their clinical training years. They should participate in providing preventive, promotive, rehabilitative services and assist in accessing curative health care.
8. In all these, curricular approaches that facilitate vertical and horizontal integration, small group learning, could be carried out.
9. Each medical college should start a Department of Family Medicine aiming to offer postgraduate programmes in Family Medicine. In the initial period this department may be staffed by faculty from the general specialties till there are sufficient number of trained family physicians. This department should be progressively involved in the training of students at the primary and secondary levels.
10. Each medical college should demonstrate a preferential option in its research activities to identifying and addressing common health problems in the local community.
11. Every MBBS student should do a community project to study a local health issue at least once in their training. This could be done individually or in small groups.
12. Students should be exposed to the training of community health workers. They should also be trained in providing health education to patients, their families and the community.
13. Students should have exposure to national health programmes and be involved in their delivery.
14. Structured courses in ethics, professionalism, communication and how to engage with patient perspectives should be incorporated in the curriculum.
15. The community based training activities should have formal assessments which should be aligned to local needs and conditions.
16. Each medical college should organize and deliver appropriate Continuing Medical Education, needs based training programmes and distance education courses for General Practitioners and health care providers in their local community.
17. Curriculum planning processes and faculty development programmes should emphasise the principle of building social accountability into medical education. Various teaching and learning approaches which promote active learning and facilitate integration may be used.
Recommendations to the Medical Council of India and the Ministry of Health and Family Welfare
1. Composition and mandate of NCHRH It is suggested that in the proposed new National Council on Human Resources for Health (NCHRH) bill, the standard setting and accreditation body should have explicit responsibility for ensuring that medical education is socially accountable for addressing heath needs of the country and should have systems in place for continuous quality improvement in Medical Education. The new Council should have broader representation to include all stakeholders such as the community, all levels of health care providers and the different health care professions.
2. Selection for admission to medical education It is suggested that selection examination for MBBS should not just test knowledge but also aptitude for the health care professions, employing objective and transparent processes. Preference should be given in selection for local students from rural and underserved areas.
3. Sub-tertiary clinical settings for training Every medical college should be required to have an affiliated district hospital or community health centre (in the state or private sector) and be responsible for the health of a defined population.
4. Enforcement of social accountability Regulation and accreditation should incorporate principles of social accountability of medical education to ensure that medical colleges are involved in service, training and research in their local communities. The accreditation process can pay particular attention to assess that the above suggestions for medical colleges are met. Suitable verifiable indicators in the community service areas may be used for the same (for example, proportion of supervised deliveries and immunization coverage).
5. Compulsory national service by graduates The proposal for compulsory rural service or service in underserved areas by all medical graduates should be reintroduced. Implementation of the recommended changes in medical education will better prepare the graduates for such service.
6. Departments of Family Medicine Priority should be given for starting Family Medicine departments in every medical college and postgraduate training programmes in Family Medicine. All medical students should receive primary and secondary level clinical training under this department.
7. CME and support for graduates during service assignments Mechanisms need to developed for convenient continuing education programmes for those who work in rural and underserved areas.
8. Addressing the disincentives for service assignments The following opportunities should be provided for doctors working in rural and underserved areas: preference for post graduate training with weightage for rural service, financial incentives, improvement in communication facilities and opportunities for education of their children.
9. Extramural Faculty Significant exposure of students to clinical care in settings outside the teaching hospital would require recognition of suitably qualified doctors working at primary and secondary level as teachers after appropriate faculty development training.
Suggestions to the new Association for Promotion of Education in Health Professions
1. Develop tools for assessing the extent to which medical colleges have incorporated the principles of social accountability to meeting health care needs.
2. Groups of medical colleges may be formed to work with one another towards developing and strengthening the concept of accountability to the local community and "co-mentoring" each other for practicing continuous quality improvement in various aspects and practices within the educational institutions.