The challenge is to acknowledge the inappropriateness of the current health education and delivery systems, and refashion health care delivery relevant for the country.
The confluence of recent events is an opportunity to rethink health systems. The new Medical Council of India, the proposed Human Resources in Health Bill, the penultimate year of the National Rural Health Mission, preparations for the 12th Five Year Plan and the promise of a significant increase in the health budget mandate such reappraisal. The poor indices of health and inequity related to class, caste and gender underscore the urgency of the situation. While diverse aspects (financing, personnel, infrastructure, drugs, governance and empowerment of communities) need to be addressed, this article focusses on medical training and practice.
Issues in training
The philosophy, nature and quality of training determine the range and value of health care services provided. The current mismatch between training imparted and skills and competencies required for practice mandates review.
Primary versus tertiary standards: Current training of medical professionals is entirely based in medical college and tertiary care facilities. Such institutions, being at top of the referral chain, serve only a small proportion of the population. They manage complex disorders using sophisticated medical technology. Doctors produced by such a system find themselves at sea when asked to serve in primary and secondary care hospitals, which manage the bulk of patients with milder, acute and common health problems, using clinical skills and low-tech approaches. The battle to provide relevant and quality health care to the general population is lost by locating medical education in specialist facilities.
Local concerns versus international focus: International traditions of modern medicine have focussed on universal conditions to the near-complete exclusion of locally relevant diseases. They also emphasise expensive technological solutions, which are out of the reach of average Indians. Physicians are more at ease prescribing low cholesterol diets for heart disease than locally appropriate food for malnutrition. Pharmaceutical and tertiary hospital industries, which cater to the richer classes, drive medical concerns.
Knowledge versus skill and competencies: Much of the training of physicians involves the transmission of knowledge. The near complete absence of skills and competencies required for practice makes most medical graduates opt for further specialist training. Today's new doctors, with major deficiencies in diagnostic and management skills, would rather apply for post-graduate courses than engage in practice. Yet, competency-based medical curricula seem light years away.
Family practice versus specialist training: The tertiary care formatting of medical knowledge and training have resulted in a syllabus based on medical disciplines rather than a curriculum with a focus on common clinical presentations and problems. Such divisions encourage specialist perspectives rather than support training concerns related to broad-based generalist education. The rarity of family and general practice departments and training, the cornerstone of good medical practice, disempowers physicians, forcing them to specialise.
Critical thinking: The Indian education system does not promote critical thought. Unquestioned acceptance of received wisdom is the norm. The acknowledgment of its inappropriateness and lack of relevance in many Indian contexts is rare. Attempts to understand the problems of practice, so crucial to the provision of holistic care, do not merit attention. The need to inculcate critical thinking among physicians, who constantly have to re-read original texts and theories, identify their limitations in clinical practice and alter received wisdom, is never encouraged.
Issues related to practice
The nature of practice and its determinants play a significant role in shaping health care delivery systems.
Universal and contextual knowledge: The dominance of medical theory, considered universal and authentic, over clinical practice, deemed trivial and less valid, makes for the dismissal of patients' concerns and context and delegitimises physicians' conflicts. Illness is confused with disease and the patient's demand for healing is misconstrued in the physician's pursuit of cures. The imperfections of practice, based on the original theories, are dismissed as problems of application and translation. Modern medicine, with its current market-driven logic, precludes working with the patient's circumstances, family, environment, culture, community and politics. Context-driven practice needs to influence, modify and change medical theory in order to deliver holistic care. These issues need to be researched and be part of pedagogy in India.
Horizontal versus vertical programmes: Many governmental health initiatives function as vertical programmes (eg HIV/AIDS, tuberculosis, etc.) with their own specific logic, goals, organisation, personnel and practice. International funding agencies also prefer such divisions, as financial inputs are easier to monitor and their impact simpler to evaluate. However, these approaches preclude horizontal integration of expertise and services required for general and family practice in primary care settings. Good integrated primary care services, so necessary for optimal health care delivery, remain fragmented and reflect the conflicts and contradictions of tertiary care formatting of medical knowledge.
Public health approaches or curative medicine: It is widely acknowledged that compared to curative medical strategies, public health approaches, which target the social determinants of health, have a much greater influence on health and longevity of populations. Nevertheless, clean water, sanitation, nutrition, housing, education and employment receive much less importance, with curative medical approaches continually hogging the limelight. Education, in general, has a greater impact on health than specifically targeted health education.
Private investment or public funding: The success of capitalism has increased the demand for private investment solutions for problems in health care delivery. Nevertheless, the unequal doctor-patient relationship with regard to medical information is fertile ground for exploitation. In addition, private capital needs to maximise profits and selectively targets diseases and services that are lucrative rather than focus on the needs of the population. While private partnerships bring in efficiency, the absence of a regulatory framework implies that meaningful health care for populations is usually sacrificed at the altar of economics. This is also true of private initiatives in medical education with their exorbitant fee structures and variable standards in education.
Indigenous research and technology: Current medical approaches employ western technology and their monopolistic pricing policies result in health care that is out of the reach of average Indians. There is a need to focus and fund indigenous research, which is locally relevant and appropriate to the Indian context. The Jaipur foot is one such example.
Universal care versus coverage: The capitalist mantra prefers universal health coverage to universal health care, with a substantial provision of services by private providers. Many States have introduced health insurance to cover for life-saving medical conditions. The unregulated and high-cost private sector provides care for low-frequency diseases in tertiary facilities, without a gate-keeping role for primary care. The absence of cover for common conditions makes the impact of such schemes marginal for the majority of the population. The consequent neglect of public hospitals also demands caution in bringing private players to manage national health care delivery.
Moving forward
Inequities in health demand critical reflection on the medical culture and clinical practice in India. Tinkering superficially with medical curricula, administrative structures and health delivery systems falls far short of any meaningful and relevant change. The challenge is to acknowledge the inappropriateness of the current health education and delivery systems to the Indian context, and to refashion health care delivery relevant for the country.
The emphasis of medical training, clinical practice and funding should be on primary health care. While physicians can specialise, their basic training should make them competent for medical practice in primary and secondary hospital settings. Medical practice should be relevant and contextual.
The gross inequity in health argues for universal health care as a democratic priority. The Pratichi Trust highlighted the inadequacy of public debate, poor media coverage and limited space in the legislative agenda for health, at the Dr. Chandrakant Patil Memorial Eastern India Regional Health Assembly, recently held at Kolkata. The Trust emphasised the fact that social determinants of health (clean water, sanitation, etc.) find no place in the public discourse. The conference also stressed the bidirectional relationship between economic development and health, which justifies much greater financial input to improve the health of populations. Media interventions to increase awareness and demand, support collective engagement and argue for health as a human right with legal entitlements, will increase the democratic pressure on governments to operationalise equitable health care. Health equity should be part of all policies — financial, developmental, environmental, educational, etc. All discussions should prioritise values rather than project practicalities. There is a need to foreground health in the public discourse. The struggle for health equity is more than a fight for democracy; it is about the definition of justice.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore. This article is based on his presentation at the Dr. Chandrakant Patil Memorial Eastern India Regional Health Assembly, Kolkata.)
Keywords: medical education, healthcare policy, rural health, health education
Comments:
Prof Jacob provides another serious policy brief for India's decision makers. The right to receive appropriate medical care, AT THE TIME OF NEED, ought to be a fundamental human right. Modern medicine is very expensive and the costs are ever increasing, partly driven by newer methods of diagnosis and treatment. Better education, greater dissemination of information, only fuels citizen's expectations. People are living longer and Indian population keeps rising. PROPER FUNDING of this human right is a major challenge for all governments throughout the world - rich and poor - and a very heavy burden for India.
For India, the issues are even more problematic in view of "Inequities in health demand critical reflection ... [on]the inappropriateness of the current health education and delivery systems to the Indian context" - as identified by Prof Jacob. India has little time to waste.
present political class has failed the country miserably as seen by the scandals,lack of control on administration, inability to protect the country from terrorist attacks, absence of priorities coupled with knee jerk reactions. This points out systemic failures indicating non functioning of checks and balances as envisaged by our founding fathers of democratic India. One possible solution is the availabilty in public domain the basis(data/other resources) for various problems/ issues before decisions are taken.i.e, the start to finish of each issue with time line. This may bring status of accountability at various levels to public knowledge.
Nice except to understand the sapping importance of clinical practice and shifting of concentration from largly prevailing diseases to the one which has lucrative treatments. The article opines for the imrovement in the current health policies to provide space and resources to strenthen the concept of health equity for all.
The article brings to forefront the question of choice about the direction of our health policy. While the country is still facing an array of problems in the public health front, but the political will to sort out such issues with a pragmatic and wider view is far from impressive. Though the country is equipped with world class medical facilities and professionals of international repute, but hardly there are any qualified doctors to serve the rural masses. The gloomy scenerio is exacerbated by low morale of the medicos who are posted in rural areas, who invariably treat such postings as punishments. When 75% of our population stay in rural areas, who are dependent wholly on Primary Health centres and Sub centres, the effort must be to strengthen these infrastructure and ensure their effective functioning. This calls for sensitising and educating the medical students and imparting in them the skills required to address problems related to basic health care in a cost effective manner.
Sir, Excellent article by Dr Jacob highlighting some pragmatic concerns with healthcare delivery and training in India. A few measures that could help: 1. Mid-level practitioners (in the US, Nurse-practitioners and Physician-Assistants)- who need shorter training periods, work in semi-independent situations - deliver primary care 2. Establishing a primary-care/family-practice track in medical curricula and post-graduate courses 3. This will need to be incentivised for young physicians to opt for it; ie--Job/lifestyle assurance (salaries/perks) 4. Encouraging outcome based research in medical curricula at an early stage (preclinical/clinical years) directed especially towards cost-effectiveness/indigenous problems 5. Significant infrastructure changes at primary health care centers (Most people with experience in these PHCs know they are inadequate in every way)6. Enforcing standards on existing medical/post-graduate training far more than opening new institutions; Just some measures.
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An excellent article, this article has to be read by all the policy makers, currently practicing physicians, medical and dental students and as a whole each and every citizen who think of future of India. The quality of our health education system has to be re checked and necessary actions to be taken immediately. Time has come to practice basics properly giving emphasis to social determinants of health and to create good BASIC Doctor's at least NOW!!!
Great article by KS jacob sir focussing on the deficiencies, the one on the coaching in the Medical colleges is most important point which leads to other isuues
I am impressed with the analysis of Dr. Jacob. One can visualise the reasons for Government's inability in dealing with the aspects mentioned in his article. I also agree with Mr. A.V.Raju, who restricted his criticism to the modern politicos. However, I strongly feel, the paucity was in the planning too, which lies in the hands of bureaucrats. Every aspect like 'vertical programmes', 'curative medicines', etc. are to be given a thought. The primary aspect, 'education' should be addressed simultaneously.
A study says that every year 3% of the middle class are crossing over to poor section of the society, while addressing their medical needs. This is an alarming situation. Don't we need a responsible political class supported by bureaucracy with vision ? Time to wake up, before it gets too late!