Merit versus social responsibility
MEENAKSHI GAUTHAM
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The goal of medical education needs to be synchronised with public health and not just with the career aspirations of students.
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More and more students from rural and underprivileged areas need to be recruited into the health system to increase the sync between providers and communities and to retain skilled providers in the primary health care system
Reorientation: The first call of the profession should be to the health of the people. Photo: K. Murali Kumar
BEFORE the dust kicked up by reservations settles down, it is time to reopen another debate on medical education — about the disconnect between blind pursuit of merit in medical education and its true social objectives. The goal of medical education needs to be synchronised with the public health needs of the country, and not just with the individual career aspirations of students from privileged educational backgrounds. On these grounds, it is time now more than ever before to look hard at both the design of medical education and its student recruitment processes, and re-orient these to meet the colossal health needs of India's population.
Least access
What is this disconnect? The large numbers of rural and urban poor in the country, who bear the highest burden of mortality and disease, have least access to skilled and well-trained medical care. The medical profession remains urban and affluence-centric while the focus of medical education is on academic excellence with micro-specialisations, at the cost of a public health or social orientation.
India lags far behind other Asian countries like Sri Lanka, Thailand and China in its levels of maternal mortality (Sri Lanka: 23, Thailand: 44, China: 48, India: 407) and infant mortality (Sri Lanka: 18, Thailand: 29, China: 22, India: 72). These are even higher among the rural and urban poor in India and can be directly attributed to poor health services, especially during pregnancy, childbirth and infancy. At the last round of the National Family Health Survey, only 20 per cent women had received full ante-natal care and only 42 per cent of children (0-24 months) had been fully immunised, the lowest being 11 per cent in Bihar. Around two-thirds of all births in India take place at home — usually assisted by family members or dais rather than by medically skilled birth attendants — and with poor access to emergency obstetric care.
We have around 6,40,000 registered doctors today and many are comparable to the best anywhere in the world. We are prominently placed on the global map of medical tourism, thanks to our specialists and super specialists. Sadly, less than 10 per cent are available in the common public health service delivery system, much less so among the rural and urban poor. According to the most recent government data only 41,191 doctors were employed by all the different government agencies in the country and only 31,480 were in position in rural primary and community health centres. Hardly a drop in the ocean for India's 72 per cent rural population!
The large private medical sector also tends to be concentrated in urban areas, and in the `better off' parts of urban areas. A study of Ujjain district (2004) found that 88 per cent of qualified medical professionals were located in urban areas and 72 per cent were practising in Ujjain city itself. In another Delhi study, better qualified doctors were far more likely to be found in affluent neighbourhoods than in the less `well off' ones.
All over rural areas in the country, there is an acute shortage of essential specialists — gynaecologists, paediatricians and surgeons. Around 40 per cent positions of specialists are vacant in public rural health centres. The entire hilly district of Tehri Garhwal has only one surgeon (a private one) for a population of 0.6 million. In stark contrast, my local yellow pages directory (I live in Gurgaon, an upcoming suburb of New Delhi) listed six general surgeons, 10 obstetricians/gynaecologists, 10 paediatricians, three psychiatrists/psychologists and an impressive array of super specialists, all within a radius of about five km. I doubt, however, if any of them would be accessible to the hundreds of migrant labourers and their families that have become a near permanent feature of Gurgaon's landscape.
So where do the rural and urban poor in India typically seek care when they fall ill? More than a dozen successive studies over the last three decades have highlighted the widespread presence and popularity of private practitioners who do not possess a formal medical qualification or training — the ones whom the medical community calls `quacks'. However they are the ones who are accessible and available when needed, and provide to their patients a sense of dignity, continuity and community kinships.
Livelihood issues
Why do rural and underprivileged urban areas have so few formally qualified providers? Understandably, questions of livelihood are critical for all graduates, especially after struggling through five and a half years of an expensive medical education. The opportunity costs and social costs of working in rural areas are too high. For those who set up private practice, better off urban areas offer far better markets and facilities. The public sector is equipped to reach skilled and well-trained medical professionals in rural areas, but the hefty wage differential between the public and private sectors does little to attract the best professionals to the public sector.
Socially, a rural posting can be excruciatingly isolating and working conditions quite challenging for someone who has spent long years acquiring knowledge and skills in an urban medical institution. In the words of a medical intern: "Doctors are extremely reluctant to be posted at PHCs for it is literally a professional dead end. There is a fear of sophisticated skills becoming rusty. Also a fear of an academic fade-out due to absence of the stimulating atmosphere that one finds in city hospitals and urban practice."
Other sore points are the unsatisfactory working conditions, lack of adequate staff and equipment and primitive living quarters. A young female medic said about her heroic attempt to live out a rural posting: "I decided to live in the doctor's quarters and went to check it out. It was impossible to live in! The place was in total disrepair, there was no electricity and the toilet was quite a distance away from the house." The trip cost her her job and the public sector lost a precious woman doctor.
Inequitable distribution
True, this grossly inequitable distribution of skilled human resources reflects poorly developed human resource policies and the abysmally low level of health spending by the government (0.9 per cent of the GDP), among the lowest in the world. Equally, many would argue, it reflects the lack of a social and rural orientation in medical education and a blind pursuit of academic excellence almost as an end in itself. The highly selective admission procedures ensure that only a small minority of very special students can make it to medical school and once in it, it is only natural for the majority to join the race for specialisations and super specialisations. This has ensured that the ownership of the profession is preserved in the hands of a medical elite who are well equipped for providing a superior quality of care and whose technical skills are highly in demand in urban affluent areas, and especially overseas. The government's National Commission on Macroeconomics and Health (2005) estimated that almost 50 per cent of graduates from AIIMS have migrated overseas. It is also said that the United States has more Indian psychiatrists than the home country. In a recent study of migrant physicians, the majority felt that physicians in developing countries learn highly specialised skills that they can better utilise in developed countries.
The current model of medical education in India was founded in 1914 on the recommendations of the Crawford Committee, an educational committee set up by William Bentinck. The Committee recommended that medical science in India should be taught in strict accordance with the principles and mode adopted in Europe. The first medical college was started in Calcutta in 1922, followed by Bombay (1926), and Madras (1927). Meanwhile, many provincial governments, missions and private organisations established another category of "medical schools" to train students for the diploma of Licentiate Medical Practitioners (LMP). This LMP course was for three to four years, often in the vernacular and geared to general practice in small towns and rural areas. Around the time of Independence, a couple of landmark developments affected the evolution of the medical profession in India.
The first Health Survey and Development Committee set up by the British Government under the chairmanship of Sir J.W. Bhore, recommended that the licentiate medical courses be abolished and that only one medical qualification — a University degree — should be the portal of entry into the profession. The Bhore Committee also provided the blueprint for an organised public health system in India, deeply inspired by the welfare state movement in the U.K. and socialist developments in the USSR. Unfortunately, the Committee did not see a role for indigenous practitioners in the modern health system; consequently a large mass of private practitioners who formed the mainstay of health care in rural areas and small towns were ignored by the new system.
The rest as they say is history! The number of medical colleges in India has grown from 25 in 1947 to 229 in 2005. Medical education has been characterised by specialisations and super-specialisations in the curative fields but this expansion has had little impact on public health in the country. India's successive five-year plans (especially the third and sixth plans) noted this gap and upgraded departments of preventive and social medicine were designed as a counter measure. But these gradually became the less favoured in terms of funding, authority and prestige.
A number of legendary medical scholars like V. Ramalingaswami, D. Banerji, and Carl Taylor advocated reforms to adapt medical education to the needs of the country. In 1976, Dr. Ramalingaswami, an eminent ex-director of AIIMS, said that the medical profession should turn from the "over-professionalised, over-centralised, over fragmented, over mystified, oversized and capital intensive system and seek out alternatives which are cheap and yet scientific and nearer the people".
Innovative reforms
Some other low resource countries faced with the crisis of overseas migrations and a lack of medical professionals in rural areas have experimented with bold and innovative educational reforms to improve primary health care provision. In the late 1970s, the School of Health Sciences (SHS) in the University of Philippines initiated a `step-ladder' curriculum for training students from rural areas.
In this design, the training of a broad range of human resources from health workers to doctors of medicine is integrated into a single, sequential and continuing curriculum. Students are selected from rural `handicapped' educational backgrounds but with sufficient literacy skills to pursue college work. They proceed through progressive levels, with the possibility of qualifying and dropping out with certified and marketable skills at each level, or progressing on to the next level. At the first level a student qualifies as a health worker, then the Community Health Nurse, then the Bachelor of Science in Community Health and so on, and at the final level is the doctor of medicine (MD) programme. The SHS programme emphasises community health relevance more than academic excellence. SHS estimate that 75 per cent of their graduates from all levels are based in rural and underserved communities and 95 per cent are still in the country. The design was extended to four other schools in 1993.
This is only one example but enough to suggest that solutions to India's health problems may not lie within the conventional medical profession. Different approaches can be developed and tested if there is a willingness to think out of the box. India needs both a clinical cadre of specialised doctors and also a cadre of basic health care providers. A long and rigorous five and a half year University degree does not have to be the only educational strategy for developing such a cadre or cadres. Shorter courses with stringent quality assurance mechanisms need to be revived and evaluated.
Most importantly, more and more students from rural and underprivileged areas need to be recruited into the health system to increase the sync between providers and communities and to retain skilled providers in the primary health care system. This would also help meet the objective of increasing social inclusion that is currently the hotbed of the reservations issue.
Of all professions, the medical profession is most inseparable from its social objectives. The first call of medical education must be to the health of the nation's people.
The writer is an independent consultant in public health. E-mail her at Gautham.meenakshi@gmail.com
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