India needs medical education that can contribute to equitable, affordable and effective health care.
Social accountability as a concept is becoming increasingly familiar to the Indian public. It spells out what society could legitimately expect from different services. Thus it challenges the service providers to explore and enhance their social contribution. It also empowers society to make the service providers answerable for deficiencies in service. This leads to the actualisation of desirable social objectives. Thus the social accountability approach can be fruitful in examining a problematic social service like health-care delivery.
There is little need here to elaborate on the deficiencies of our health care system. The health-care deficit in India is a matter of daily distressing experience. But this intractable crisis in health care, which is a matter of life and death to individuals and cripples the nation, does have effective, though not perfect, solutions. These call for changes both in the way health-care delivery is organised and the way medical care itself is practised.
This article aims to explore the applicability and implications of social accountability in one important component of health-care delivery, namely, medical education. Can modifications in medical education contribute to the equitable, affordable and effective health care that should mark a healthy society? Countries like Cuba and South Africa have demonstrated how medical education can be modified to this end. If so, can this privileged and almost sacrosanct segment of professional education be held accountable to society?
Seminal role
Unlike many other professions, a major part of doctors' education occurs in institutionalised practice situations with close mentoring by practising role models. This long period within the walls of medical colleges sets the prism through which their graduates view their profession. And their perceptions are self-perpetuating because they profoundly influence society's own understanding of what constitutes “good” health care.
In a landmark publication on “Social Accountability of Medical Schools” (1995), the World Health Organisation identified four core values that socially responsible medical colleges should embody and disseminate: relevance, quality, cost effectiveness and equity. If medical education can be reoriented towards these four values, gradually the medical profession will come to practise them. But Indian medical colleges now focus almost totally on quality, or “uniform standards” as defined by specialist-oriented tertiary care. They do not emphasise competencies required for medical practice. The lack of basic skills undermines the confidence and the inclination of physicians to successfully practise after graduation in settings of primary care and secondary hospitals which are alien to them. And these precisely are the settings where India's health-care system is most at fault.
Rethink among educators
Recent events have raised hopes of some salutary developments, within the medical fraternity and among the general population. The reconstitution of the erstwhile Medical Council of India (MCI), the proposed National Council for Human Resources in Health (NCHRH) Bill, and attempts to restructure the core medical curriculum set the stage for this optimism. There is ambitious talk of having a medical college in every district. It was in this context that educators in the health professions from across India came together recently at the second National Conference on Health Professions Education in Vellore. This conference broke new ground by choosing as its theme “Socially accountable health professions education.” Their Concluding Statement (The Hindu EducationPlus, Tamil Nadu edition, October 24) made a set of comprehensive recommendations to medical colleges, the Medical Council of India and the Ministry of Health and Family Welfare so as to align medical education “consciously towards improving health and health-care provision for the people of India.”
The basis of their road map for change is that the learning environment of future doctors should encompass all the links in a model health-care system extending beyond the present teaching hospitals to secondary-level hospitals and primary health centres. The setting of their training should convincingly demonstrate how all the levels of health-care work together to provide optimal care to the community. For this, medical colleges will need to develop formal and effective linkages with the local district hospital, taluk hospitals and primary health centres, and also be responsible for the health of a defined population. Medical college faculty members should be engaged in teaching and clinical care at all these levels. Suitable health-care professionals in the health-care system should also be involved in the training programme. In their research activities too, the colleges should give preferential attention to analysing and addressing the health issues of the local community.
Admittedly, these call for breaking new and difficult ground. In the state-run medical colleges, the Directorate of Medical Education and the Directorate of Health Services will have to work together to make these possible. In the proliferating private medical colleges, public-private partnerships will have to be worked out to provide optimal health care to chosen communities.
Graduates of such a training programme grounded in the Indian realities will be able to serve as competent basic doctors in the health-care system. The nation should avail of their contribution to solve the pressing health-care needs through a period of compulsory service immediately after graduation. Continuing Medical Education programmes should be on offer for further professional development of the graduates during this period. As the academic discipline undergirding professionally sound generalist care, every medical college should have a Department of Family Medicine and offer postgraduate training in this discipline.
The way forward
How can medical colleges be held socially accountable in the likely scenario of rapid expansion of undergraduate and postgraduate medical education in India? About a third of our medical colleges are already in the private sector. And further growth of medical education is likely to be mostly in the commercial segment that aims to make a profit out of offering entry into this lucrative profession. In their services too, they would prefer to concentrate on the upmarket “plums” in specialist tertiary care. In such a context, only a regulatory system committed to social accountability can ensure the desired changes.
Therefore, in the proposed NCHRH Bill, the new Council should be mandated not only to ensure uniform and high standards but also to make medical education socially accountable for addressing India's heath needs. Our experience with enforcing social obligations in other sectors (for example, the telecom industry) highlights the difficulties of implementing such mandates. In order to ensure the required commitment to a social as well as professional mandate, it is particularly important that the new NCHRH should have a broad representation to include all stakeholders, and not just the leading lights in the health professions. Far-reaching as these proposals are, the impending changes in the regulatory framework offer a window of opportunity to ensure social accountability in medical education, and to actualise the vision of equitable, affordable and effective health care for all people.
(Dr. P. Zachariah was a Professor at the Christian Medical College, Vellore, Tamil Nadu.)
Keywords: MCI, health care sector, NCHRH, Health Ministry
Let me say at the outset that I am a graduate of CMC, Vellore and that Dr P.Zachariah was one of my teachers. I agree with most of what he is saying especially getting more medical graduates interested in primary care. That is going to be the tricky part. Many newly minted medical graduates have other plans. They have been exposed to many new technological advances during their training and a career in primary care may not hold much attraction at that point in their careers. They are infected with the specialization bug. The only way to ensure a steady supply of health care professionals to provide primary care to the Indian public is to make it mandatory that new medical graduates serve in needy ares for a period of two years. Once this commitment is met they can go onto an area of specialization. The other option is to empower the use of 'barefoot' doctors pioneered by the Chinese.
Having a medical college in every district is not possible,but there must always be an audit like process by the senior medical officers from the state/centre confirming whether the common man are being treated properly or not. Even its really a very shameful act of indian government that day by day they are increasing the number of medical colleges in the country but it is not at all able to improve the health treatment of poor people at rural areas. there must be mandatory rule where Docs being placed at rural areas should get more pays than Docs at urban areas or being at private hospitals. In this way we can improve the health care of peoples who are not in the lime-light.
The Growing population of our country specially rural needs a better health care facilities for sustainable life.As WHO regional adviser said Higher spending on health to push Indians to poverty(The Hindu news Nov.8).It is a warning to strengthen our health infrastructure,primary care facilities,better mobilization of these are must needed.Most of deaths are frequently caused by inaccessible or un-affordable health facilities.NCHRH and Bachelor of Rural Medicine course could provide, to a great extent,social accountability of medical professions.
India needs to start Diploma in Medical & Health services wherein aspirants are educated and trained to provide basic Medical and Health services viz. Clinical washing, Bandages, BP check, Fever Measurements, Cough, Colds, Vaccinations etc. They may be required to tie up with Doctors or Hospitals for referral of patients to Hospitals & doctors needing treatment of higher level & surgicals. This would reduce pressure on Public Hospitals and people would get services at lower / affordable costs.
A five year MBBS after 12 th standard is a very short. There should be a course that will allow those that did not make it to MBBS to complete basic anatomy, physiology, biochemistry and statistics along with psychology and ethics - with an entrance exam at the end - and mandatory research experience - to go into sub fields like radiology, nursing, obstetrics, osteotechnology. Basically mini doctors that can classify the further course of referral to specialist based on symptoms and diagnostic tests - that should be standardized to reduce the job of the doctor. If the doctors job is chipped away into smaller parts and disseminated to many people educating and employing many there will be a focus on quality. By increasing the duration of the study and having research in every health center of every village and town - with mandatory ethics and empathy education - quality of health care will change.
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