Medical education must be reoriented towards equipping doctors for primary and secondary services. Only this can help India achieve universal health care
The increasing visibility of the concept of Universal Health Coverage (UHC) in the public discourse on entitlements augurs well for the country. One auspicious sign was the appointment of a High Level Expert Group (HLEG) on UHC, headed by the highly regarded Dr. Srinath Reddy, by the Planning Commission. In a recent article (The Hindu, April 14), Dr. Reddy, along with another member of the HLEG, summarised its recommendations for achieving UHC. The ambitious goal is to deliver an assured “essential health package” to all citizens of our far-flung and populous nation. But our starting point is near the bottom among nations: 112th in the quality of health care and 145th in per capita health expenditure. Thus, UHC seems a much needed but overambitious goal for us.
India leads
However, there is one health-related resource in which India leads the world, namely the number of medical colleges. We have over 330 of them and the number is set to increase to at least 400; by then the annual output of medical graduates will exceed 50,000. This article argues that prioritisation of primary and secondary level health care is basic to UHC. And a reorientation of medical education to that end can mediate this transformation speedily and durably.
Ninety per cent of all health care needs in any community can be delivered through primary and secondary level facilities. These include Primary and Community Health Centres, taluk and district level hospitals and their equivalents in the private sector. We will refer to them as subtertiary care i.e., clinical services below the level of teaching and corporate hospitals and other speciality oriented centres. The major causes of mortality and morbidity can be identified and treated effectively in their early stages at the subtertiary level, at affordable cost and within easy reach. Also, through vigorous promotion of health education and public health measures, the subtertiary centres can reduce the incidence of these conditions.
But without such care, these diseases proliferate and reach catastrophic levels both in numbers and intensity. They then overload the scarce resources at the tertiary level, draining the finances of families and the state, and often with little prospect of relief or cure in the late stages. Thus provision of competent subtertiary health care is the foundation for UHC and without it, a superstructure of “world-class” tertiary centres is of no avail. A comparison of the U.S. and Cuba will readily demonstrate this.
Just as headmasters play a pivotal role in school education, the availability and competence of physicians are basic to the success of subtertiary care. Ensure the availability of “capable” physicians in adequate numbers at this level and half the battle is won. But this capability is no less demanding than any other branch of medicine. First of all, the physician needs to win the confidence and trust of the community by offering dependable medical care, covering most of the common health care situations within limited facilities. In addition, he has to provide leadership for a variety of health-related activities, mediated by a large team of diverse non-medicals, not all of them adequately equipped and motivated for their tasks. The physician's performance as the conductor of this complex health care orchestra depends on how well the medical colleges prepare him for this role and also on societal recognition and rewards. In India, the academic discipline (or medical subject) that deals with subtertiary care is known as Family Medicine. Sadly, this discipline finds no mention in our MBBS curriculum. Naturally the emerging physician is ill-equipped for his role in subtertiary care. Nor does he find an informed public appreciation of this role.
Formative influence
Physicians are “formed” by medical colleges as much as priests by seminaries or army officers by defence academies. The imprint of the priorities and practices of the teaching institution stays with them for life. At present, these emphasise speciality care. And that formative influence shapes not only the careers of physicians but ultimately the public perceptions of health care at large. For, it is the medical community which modulates society's perception of what good health care is. Thus if medical education is reoriented to prioritise subtertiary care, that shift in the fulcrum will eventually move the mountain of UHC through modulation of both professional and public perceptions. Increasing the number of medical colleges, inevitably in the urban centres, will by itself be of little avail for UHC till we agree that all colleges, old and new, should teach a kind of medicine which prioritises subtertiary care.
If we agree on this priority, we will have the means to bring it about. Over the last 80 years, the Medical Council of India has so consolidated its hold over medical education that we now have a very effective regulatory mechanism though there have been grievous lapses in its operation. Thus it will be possible for the Medical Council in the course of 10 years or less to bring about the changes in medical manpower that will sustain UHC in the years to come. Four essential and sufficient steps are outlined below.
Family medicine
All medical colleges must be required to have a Department of Family Medicine (FM) with a decisive role in undergraduate education and the potential, eventually, to offer postgraduate training in FM. In addition to the present teaching hospitals, all medical colleges must have attached primary and secondary health care facilities (in the private or public sector) whose clinical services they will help to strengthen and where students can effectively engage with subtertiary care under the supervision of the FM faculty. Speedy development of the initial faculty for FM departments is crucial. A crash programme will be required to produce the founding generation of postgraduates in FM. One option is to establish schools/institutes of FM in some 15 selected medical colleges, each capable of training about 15 faculty level family physicians every year. Some of these colleges could also be permitted to offer a combined MBBS-MD (FM) seven-year course, into which a significant proportion of undergraduates could be directly channelled.
For the transitional period, selected senior faculty from the general medical specialities (General Medicine and Surgery, etc.) could double as the transitional faculty in FM after suitable reorientation. When these steps are fully implemented, post-graduation in FM will become a challenging avenue for medical graduates across the country and it will have an adequate corps of well trained family physicians who, along with the new graduates trained by them, can take the subtertiary services to their full potential.
How can we bell this cat?
Expand objective
What is suggested is in effect a significant expansion of the objective of medical education and of the mandate of the bodies which regulate it. From its inception in 1933, the MCI's educational function has been restricted to ensuring the “standard” of professional education. There was no attendant societal commitment except monitoring professional conduct. And this pattern has been followed by the other health-related Councils. Left to themselves, such bodies are hardly likely to initiate or implement the suggested transformation.
If such changes are really to come about and endure, the regulatory body must be directed by its enabling Act, “to ensure that education in the health professions will promote universal health coverage in the nation.”
By a curious turn of events, the entire regulatory structure for the health professions in India is being restructured. In the new structure, human resource for health must be seen not only in terms of numbers and professional standards but also as the agent for ensuring equity in health care. The Bill on the National Commission for Human Resources for Health is still on the anvil. Now is the time for socially conscious health professionals, civil society and the political leadership to work together with clarity of purpose and the required haste so that a commitment to UHC is embedded in the very mould which fashions health professions.
(The author was formerly on the faculty of Christian Medical College, Vellore. His email: p_zachariah@hotmail.com)
Rural Health Mission must be upgraded with a special branch of medicine based primarily on sound clinical assessment and mangement practics in indian healthcare system.Rural health Mission must be made attractive with proper instituional training to a set of youngstars who are interested to serve in rural india .It needs separate mission and vision with scintfic but low cost efficient one in contrary to corporate style healthcare system.
Thank you Dr.Zacharia and The Hindu for an informative and thought provoking article.The idea of Family Medicine(FM)and seven year course of MBBS-MD(FM)is really an acclaimed one and MCI and Ministry of Health and Family Welfare should give atmost consideration.Its really sad to knew that the concept of Family welfare doesn't appear in the MBBS Curriculam.I think the facts that more than 330 medical college and annual output of 50000 medical graduates in India is really appreciable one eventhough our GDP expenditure on health care is lesthan 2 percent.
Shukkoor.T
Research scholar
Department of HSS
IIT Kanpur
Kanpur-208016
U.P,India
the sub tertiary level is a mess. even doctors who are willing to work at the level are put off by the corruption & inefficiency. A friend in health service who is from a rural area requested posting to a PHC near his home. he was denied despite there being vacancies. another surgeon requested a Taluk hospital with the surgeon post vacant, was posted to a dist hospital where a surgeon was already there. when he requested again he was sent to a mobile tribal unit, which was a waste of his surgical skills. the reason why the posting of your choice is not given is that the office staff expect a bribe. my friends refused n & resigned from the service. hearing these n many other similar stories i have myself refused two appointment orders from health service. despite that i know many medical graduates who are willing to work in health service if such such headaches are taken care of.
I'm from kerala & situation is different in other states
Give both a GP and a super specialist doctor the same package.You will see a drastic
drop in people going for the specialities.90% of Indian graduates are money driven.
Put a cap on the renum.package you will only see genuine ,dedicated students
coming into medicine for the love of the profession.
Humble questions for P. Zachariah:
(1) What is family medicine? Is not family medicine the sum of Internal Medicine, Pediatrics, Gynecology, Emergency Medicine, and a large amount of holistic hubris?
(2) How will the future faculty member selectors objectively screen the prospective professors from the "senior" members of the medical faculty? Professors have been observed to ignore known values for specificity suggest CT scans of the head for temporary confusion in elderly people during acute illness, test Plasmodium falciperum antigen during an attack of fever, or measurement of plasma concentrations of triglyceride and lipoproteins in a middle aged patient with "vasovagal" attack. Other professors ignore known values of sensitivity by omitting chast X ray in elederly and very young patients with pneumonia.
(3)Like the Osteopaths in the US the Homeopaths and Aurvedics here are satisfactorily trained in primary care medicine. Is not training them more economical in money and time?
how many of us discussed the point of rural health care? hospitals which
are in rural areas area in delapetating condition.It is well said to strengthen district level panchayat level health care.Doctors who are
studying in India and serving other countries is also a cause of worry.
I admire the writer for his great thoughts.It has nothing to do with the
number of medical colleges we have,It is that whether a common man can
afford the treatment.so the bill should be passed.
How many of these medical schools r international standard? Most of them are opened by govt/mp's relatives simply to make money. some of them don't even have fully furnished pharmacy and the emergency room with all the necessary equip.
Universal Health Care and the number of medical schools both existent and upcoming are all well and good. What really needs to be looked into with more scrutiny is the actual level of education being received by the individuals entering and leaving these medical schools. With the quota system in place, the number of people graduating medical school with literally a License to Kill is astounding. Whether or not you set up a Family Medicine training division, as long as there undeserving MDs out there with a License to Kill (read: MBBS certification with no actual merit), the morbidity and mortality rates in India will remain high. Sub-tertiary care from a 3 year old with a toy syringe and a license to scribble a prescription probably would have the same result.
i appreciate the author's initiative in enlightening with the ground situation of medical facilities prevailing in the country which though boast to have hundreds of medical colleges and tons of graduating doctors but is always abashed with the graphs of deteriorating health care. I strongly avers that prioritizing subtertiary care will help us escape this predicament.There is an immediate need for the young doctors to understand the ethics of their profession instead of running behind making money out of it. they should not mind being deployed in rural area. the country has a lot of potential what lacks is the policy to utilize it.
Let us be practical.The doctors trained in private medical colleges will never fit into Dr. Jacob's utopian philosophy. So more than half of the medical graduates are taken off. The medical graduates from Govt. won't be satisfied to do rural service as family physicians for a small salary which won't even fulfill their basic demands in this contemporary highly inflated India.A govt. doctor with the current salary can never dream of owning a house in India.So as usual the doctors from Govt. medical colleges will try to settle as a superspecialist or flee the country. The real solution is creating a doctor assistant course for 2 too 3 years. To manage all the primary care and public health you don't need such a long education.all that you need to know how to use common antibiotics and pain killers. You don't need a postgraduation to work in rural or towns. You only need people who are humane to the fellow citizens which you can't expect from the Medical graduates(that includes me also)
The reason for medicine students to seek specialization is merely a pecuniary one. A specialist doctor can earn much more than a general practitioner, and work at a well-paying private hospital which has not only a lot of money to offer him/her, but also a comfortable environment and fewer cases to handle. Add to that the ruinously expensive fees at medical colleges and the "donations" and the medicine student has no motivation to follow any ideologically motivated higher purpose.
Moreover, a doctor will want to practise in the city where he has more, better paying patients and a more comfortable environment, instead of rural areas where >most of the poorer patients live.This problem can be observed not only in India but also in richer countries. One solution would be to introduce a "numerus clausus" which caps the number of practising doctors of each kind in a district, forcing them to explore other avenues such as practising in rural regions. It's a bit draconian but may work.
Family medicine is no longer a dream in India. Earlier there was no
ownership for this speciality. To say that young doctor are not
interested in family medicine is not whole truth, when they have been
never been offered this option or opportunity. As an academic
discipline family medicine is much advance to the traditional general
practice prevalent in India. Many perceive family medicine training to
be extended rotational internship which is a misrepresentation. As
rightly mentioned in this article, since family medicine concept does
not appear in the MBBS curriculum, most students, young doctors and
even several senior faculty do not know about its rich body of
knowledge. Family medicine cannot be just part time teaching as
suggested by some. It has to be a full fledged department linked with
university based medical education system. Many post graduate
qualifications have been hyped and are sold at high price in medical
education market. Family medicine offers freedom to the young doctors
from the vicious cycle of exploitation and insult. Family medicine
offers parity to the community based physician with respect to the
organ based specialists. It also equips them with right skill and
competency to be able to tackle majority of the health problems in
community. It is no wonder that many groups feel threatened from the
rise of family medicine. For more details on family medicine in India
visit Journal of Family Medicine and Primary Care (www.jfmpc.com)
A very good and to the point analysis of current scenario.
A respondent above has pointed out the inadequacy of General Medical
Practitioners. This is a serious disadvantage. Every medical man wants
to be a specialist these days. So, patients are forced to go to
specialists directly which was not the system envisaged. What are the
authorities going to do in this regard? YOu cannot achieve this merely
by sisuing rules.
Fantastic article! What a special person the writer is! I will forward
this article to some of my friends. In a crisp article, a beautiful road
map to improving healthcare in India has been drawn. Thank you.
There should be modifications in the school education system too. At the
high school level there should be some subjects which teach about only
our responsibilities towards society and developments of our nation.
. I emphasise this for recently the media revealed us the horrid story
of a rural district hospital. A woman in labour pain came to the
hospital in Guna (MP)in an auto. Even as she entered the hopspital he
gave birth to a baby. As the papers were being prepared –in the usual
leisurely manner- the mother and the new born were lying on the
verandah of the hospital. The pigs roaming the hospital compound made
feast of the new born baby and it was a good samaritan who was
paassing by who drove away the pig and saved the child. . What are
the DG,Medical Services for?
Recently, deaths of new born babies were reported frequently, the
famous cases from Kolkatta and Jodhpur. It was stated that between one
child birth and another, there was hardly any time to sanitise the
labour room. Here again medcial profession’s resonsibility comes
forefront. As for corproate hospitals, I have found that their calls
from their public relations department were more than the visits of
seniors.
Is there any study, which shows that what is the combination of patients, a MBBS doctor sees in an OPD or a private medical practitioner attends daily? There will definitely be repetition of prescription in most of the cases as most the problems will be common. Hardy in a few cases knowledge gained during the MBBS course will be used. Therefore every educated person must be provided the basic knowledge to common ailments so that they need not to rush to doctor for a simple problem. Few steps can be taken in this regard. 1. Identification of area to be covered under medical education related to primary health care, special and super-special. 2. First aid should be part of school curriculum for the students of Secondary/Sr.Secondary level of all streams. 3. Primary areas should be taught to each student in under-graduate level. Why a MBBS degree required for that. Auxillary Nurses are not lady doctor but doing excellent work. Most of the common diseases can be treated at home using Allopathic, Homoeopathic and Ayurvedic treatment. 4. There should be courses like B.Sc(Primary Health) open for any student with say 60% marks and they should be permitted to practice after successful completion of course. Preference should be given to students of rural areas. This will eliminate the menace of jhola-chhap(fake) doctors. These persons can also be attached to their respective panchayats. 5. In MBBS a few seats should be earmarked for the persons of rural area and those who intend to work there for a minimum period of say ten years. They should be paid higher than the person employed in areas other than rural. Any violation to this may leads to termination of their degree. 6. MBBS doctors should only attend the cases referred to them by primary health workers. This will remove the requirement of compulsory rural service for getting a medical degree. 7. Private Medical Universities may be barred and seats in Govt. medical colleges be increased.
There is an urgent need to streamline medical education and to
derecognise and scrap the recognition of so called 'medical
colleges'which do not comply with MCI norms.The whole idea of
capitation colleges is so wrong that that the products churned out
have hardly any motivation towards their profession.Also gone are the
days when you could find good dedicated faculty to motivate and guide
these students them better doctors.The solution is not to establish
medical colleges at every district headquarters,but to upgrade the
existing secondary and primary centers to world class centers where
most of the common surgical and medical problems can be managed at
that level.A need is there to promote Family medicine practitioners
and offer them adequate incentives to serve in remote areas.
Also Health economics should be made a vital part of the curriculum so
that new graduates as administrators learn to handle sparse resources
in a effective way.
Glorious thoughts.Kudos P. Zachariah. The question at this juncture is ,will these thoughts/suggestions ever be noticed by responsible personnel & Departments?
As rightly said by the Author ,trying to build quixotic palace on the weak fundamentals is just utter waste of resources.Hope the Universal Health Coverage (UHC) will not be one of those damp squibs rolling out of UPA on a regular basis in the form of welfare schemes.
There are 3 year graduation course in medicice (BMS) in certain parts outside india. They get employed in rural health centres. They are not allowed to carry surgery procedures. This is missing in india. In india Mbbs students are under serious pressure and 90pc of them are indoors preparing for pg admission in india or working for USMLE OR PLAB. When the specilisation takes ten years to achieve, it is also unrealistc to expect the specialists to hang
in unremunerative locations. Let the planners take a practical view.
Apart from such steps, which is author mentioned, such as orientation
in medical programs, Primary/Secondary health service, health
care/physician facility to reach to people, few more policy change are
much need for far-flung and populous country like India. Those are,
1. Initiative of Government free health programs and campaign to
make alert on various life threaten diseases.
2. There should be health safety hoarding in main market place.
3. Specialized medical experts seminar to be arranged often in
urban areas as well as rural areas.
4. Most importantly, generic medicine store are much needed
requirement for the Indian hoi polloi, because still India is in 50%
slap category, while dealing with poor people head count. Major
beneficiaries are the company and the doctors and poor people are
victimized of a money drainage system.
all the steps mentioned here and the concept of family medicine is definitely a well thought solution, the concern lies in the participation of doctors to be a part of such movement, the idealistic and objective views mentioned here seem too far from reality.
Noble thoughts. A dream that I dream will be reality. I am lost though. The author, am sure can help. Medical seats, I understand, are sold as "packages" like holiday packages. If that be the case, how can we realise what is written. How will a student let himself or herself be "formed" as the author would like them to be? As long as the issue of capitation fees are not dealt with firmly, college education will not produce the output that we keep dreaming of.
The recommendation offered can bring a telling change in the UHC and overall health scenario in the country. I agree with all that have been said I just want to add this point. I think there is also a need for change in the medical entrance exam papers and patterns. Most colleges test the students in biology, physics and chemistry. I fail to understand the practical use of knowing how the gravity varies with altitude or the basics of rocket science and nuclear science in the profession of doctor. What is more >advisable is to test the students of their social and human understanding. Include the subject of human & social psychology in medical entrance exams. Just check if they know the implication of saying no to a patients only because he/she can't afford the expanses, whether he/she knows the implications of not attending to the patient in time and whether he knows or not how to handle a patient tested HIV+ or how to deal with kith and kin of a deceased patient.
I feel that a six to twelve months diploma course of subtertiary care should be offered. Because the doctors who had spent 5 to 7 years to achieve there degree are not interested in advancing their career in FM. Nor they are interested in carrying there practice in villages and towns. A department of FM should be created as an autonomous body that should setup it offices in villages and towns to provide subtertiary care.
Universal health coverage which ensures proper health care for all irrespective of social and economic strata is quintessential for country like India where 40 per cent of children are underweight and almost 60 per cent are stunted as per recent HUNGAMA report. Approximately 1.72 million children die each year before turning one. The public expenditure in health in our country is at very low level. India spends about 2% of its GDP in health.The Government must cutback its expenditure on subsidy and increasing its spending on health for upgrading existing health infrastructure and setting up new ones.
Desire for becoming a Super Speciality Doc has been the main Aim's these days for the Young Medico's. What India Needs is a handful and adequate no of General Practioners. What i feel is that, the Young minds in the Medical Colleges should be Imbibed with Knowledge and Awarness about the Challanges, our India Faces, this may lit some fire in them. Afterall, Good Education and Very Good Health Services are required for Building a nation. And its sustainability and Growth Depends on that!!
Sadly there is no curriculum for undergraduate and post graduate medical education in India. Everyone including leaders in healthcare professions wrongly name syllabus as curriculum. Making a national curriculum would be a first step towards modernising medical education in India. This will follow quality assurance.
Ajo John, MBBS, MS, FRCS Edin, FRCS Eng, PGCertEduc
I agree with the author's proposal for Family Medicine training. In fact the regular MBBS practice is supposed to be just that, but we are not trained for the role. However, I disagree with the number of colleges and graduates observation. India has 1.1 billion people and over 500 districts. I think there should be professional education at each district level to help retention locally.
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