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 NRHM Task Force Detailed Report

Important Excerpts

OBSERVATIONS & RECOMMENDATIONS ON MEDICAL EDUCATION

from
REPORT OF THE TASK FORCE Appointed by National Rural Health Mission (NRHM)
Aims & Objectives
In December 2005, the National Rural Health Mission (NRHM) under the Ministry of Health & Family Welfare, Government of India constituted a Task Force to study the Public Health Care system and condition in India in context of the medical education provided to the service providers, principally under the ambit Medical Council of India (MCI), and suggest measures in the medical education systems in such a manner, so as to provide direct inputs in improving the Public Health Care.

Important excerpts, from the report of the Task Force, especially in context of Reproductive, Maternal and Child Health Care and the way such recommendations are assimilated in NARCHI’ s objective and methodology, is reproduced below.

NARCHI was founded on similar ideas and objectives way back in 1970’s, but has since assimilated all recommendations of the report in its efforts, provide and improve Reproductive Child Health, both by direct intervention and through academic training and evaluation of MBBS graduates through Dr. C S Dawn ICMCH.
  1. In 1992 the National Institute of Health and Family Welfare (Status Study of Training in MCH &FW in Medical Colleges of India, NIHFW, 1992) carried out a significant study on the effectiveness of the training given in the graduate course on issues relating to Maternal and Child Health and Family Planning. This showed that a large number of fresh graduates had no knowledge of simple procedures and conditions, like: immunization; nutritional advice; IV Fluids; oral pills; IUCD; etc.
  2. Another survey conducted by Community Health Cell-Bangalore, focused on medical graduates with at least two years experience at the primary care level. The survey showed that they required improved knowledge and skills in many areas, including: basic nursing procedures; emergency medicine; minor surgical procedures; obstetrics; and local anesthesia. They also needed to gain experience in running a small laboratory, assessing community health needs; delineating simple programmes for training health workers; etc. They suggested some improvements in the graduate curriculum: integrated teaching focusing on common problems and clinical applications; reduction in the basic science subjects; and increase in responsibility and decision-making in the course of ward work.
  3. WHO –SEARO Study 1995: This study noted a disconnect between the focus I the syllabus by way of teaching / examinations and the actual morbidity pattern observed at ambulatory level.
  4. The shortcomings perceived by the fresh medical graduates are principally the outcome of their urban orientation and the skewed pattern of their aspirations. Most of them have only lived and trained in the urban setting. The few with a rural background acquire an urban mindset in the course of their training that is focused around a tertiary care hospital. They do not have the confidence to function in a setting in which there is no multi-disciplinary support or advanced diagnostic hardware. Most graduates aspire to spend their career in the same urban ambience that they are familiar with. This is, in a way, a distant ripple effect of the macro trend of the commodification of health services observed globally over the last two decades.
    It is often felt that it is because of this fixed mind-set that the young graduates fail to position themselves comfortably in the social ambience of the country, and also fail to recognize health services as a fundamental requirement of the community.

    For medical education to serve the community, it would have to be socially oriented towards primary healthcare. The pedagogic methodology would have to be problem-based – where the non-clinical principles would have to be meshed with clinical training. In short, it is felt that medical training should largely be in a decentralized setting outside a tertiary care hospital, in close proximity with the public health and social environment.
    And with a different orientation to the curriculum, and a community-centric pedagogy, one can reasonably expect a much more even spread of service providers over the country. Package of Reform
    'The Task Force discussed the shortcomings of the MBBS curriculum in detail and came to the conclusion that certain significant modifications / additional elements are required to be introduced immediately. The recommended additional features of the syllabus are discussed hereafter.'

    ICMCH has assimilated points 1 to 4 above

    NARCHI realized that a significant number fresh medical graduates lack adequate knowledge of simple procedures and conditions, like: immunization; nutritional advice; IV Fluids; oral pills; IUCD; etc.

    Dr. C.S. Dawn ICMCH was thus established in 1992 to provide them with training and making them confident and capable of handling situations which they were academically qualified to do so under the ambit of MCI.

    Though there were adequate colleges providing theoritized PG education there was no institute to provide hands on training. Thus an untrained medical profession created though inadvertently, was too gruesome to conceive.

    Dr. C.S. Dawn ICMCH thus provided much needed training, albeit to a very limited number of candidates due to limitation in resources.

  5. Rural Orientation Package
    1. The Task Force has earlier commended on the attitude of the medical graduates that are produced by the existing educational system. By and large they carry the values of the urban middle class. Even those from a rural 30 background are unwittingly co-opted into the urban milieu, discarding their social roots. As a result, fresh graduate doctors have no concept of broad community healthcare needs. Their professional world-view, regardless of whether they pursue a career in the public or private sector, is of providing curative services with considerable high-tech backup. Professionally they aspire to specialize in one or the other clinical disciplines, and their skills are organically linked to the back-up infrastructure of a tertiary care hospital. The Task Force sees the lack of an understanding of broad community health needs in the fresh medical graduates, as a critical deficiency. This results in a misconceived approach to primary healthcare, whether in the public or private sectors. There is an inordinate reliance on curative care and high-tech diagnostic tests on the part of the service providers.
    2. The training should be in batches of 20-25 students. The training package should include an exposure to the principal facets of the rural community, covering aspects like: agriculture, other occupations, local-selfgovernment institutions, health & education facilities, markets, transport & communication, family structure and dynamics, caste and communal dynamics, cultural and religious traditions, festivals, local maternity and child health practices, etc. The students should also undergo training on the roles of the various public healthcare functionaries (Health workers, Health assistants, Anganwadi workers and ASHAs) by attachment to these functionaries. This would expose the students to the national health programmes as implemented at the ground level.
    3. The four weeks of field activities shown in the above schedule should require actual stay in the villages. Medical colleges should make reasonable arrangements for the stay as are appropriate to a rural setting. Past experience has shown that students do not pay adequate attention to the portion of the syllabus connected with Community Medicine. To discourage this tendency, the Task Force recommends that 20% of the total marks of internal assessment in Community Medicine be allotted to the assessment of the student during the rural orientation training.
    Some medical colleges - AIIMS, New Delhi; St. John’s Medical College, Bangalore; Christian Medical College,Vellore; Mahatma Gandhi Institute of Medical Sciences, Wardha; and JIPMER, Pondicherry - have experimented with such rural postings and they could be associated in the exercise for drawing up national guidelines for other institutions.

    ICMCH has assimilated point 5 above

    Agreeing fully with the recommendations of the Task Force that for Medical Graduates to serve effectively at the PHC level they have to be rurally oriented. Dr. C.S. Dawn, ICMCH, includes the following in its training curriculum. a) Compulsory training at a rural centre identified by the fellow guide, for 3 months, within the 2 years period of training. Plans are underway to have this period certified by not only the Fellow Guide (currently) but to the candidate being allowed for evaluation. b) Distribution of Dawn Rule of Ten Calendars. This calendar is one of the simplest extremely cost effective techniques to reduce infant and maternal mortality. (Contents attached)
  6. Prioritizing the Curriculum and Enhancing Skill Development.
    1. The medical colleges in India have traditionally followed a curriculum stuffed with information. With the explosion of medical knowledge in the last half century, the students are faced with an ever-increasing burden of information. It is necessary to find a way to cope with this problem so that space can be found in the curriculum to impart to the students the clinical knowledge and hands-on experience that is so necessary. One way would be to prioritize all the information in the medical field so that appropriate attention can be given to the different categories.The medical colleges in India have traditionally followed a curriculum stuffed with information. With the explosion of medical knowledge in the last half century, the students are faced with an ever-increasing burden of information. It is necessary to find a way to cope with this problem so that space can be found in the curriculum to impart to the students the clinical knowledge and hands-on experience that is so necessary. One way would be to prioritize all the information in the medical field so that appropriate attention can be given to the different categories.

      Conceptually, the categories could be as under:
      Must learn/ essential.
      Useful to learn/ should learn.
      Nice to learn/ may learn/ additional – but does not need to be given the same emphasis.
      Given these categories, one could even hypothesize as to how much study time should be given to each category. In order to provide adequate skills to operate independently in the primary healthcare domain, as a subjective assessment of the Task Force, we would suggest the allocation of study time to the three categories in the ratio of 6:3:1. Such an allotment of study time would enable the student to concentrate on the ‘hands-on’ skills for providing service in the primary healthcare area. More study time would be available to acquire the various essential skills for independent functioning - psychomotor and performance skills; attitudinal and communication skills; judgment to take decisions on balance, without access to accurate evidence.
    2. Certain Medical Colleges and Health Institutions (e.g. AIIMS-New Delhi, RGUHS-Bangalore) have undertaken such exercises and the scheme has been incorporated in their syllabus. The MCI should build upon this and develop a model curriculum relevant to the NRHM. The classification of items in the curriculum would assist the teachers in the medical colleges in creating course material in proportion to the importance of the three groups of knowledge.
  7. Ministry of Health and Family Welfare
    • Skill oriented examinations.
    • Move marks to internal assessment & Practical.
    • Inadequate hands on skills of fresh graduates.
    • Internship not taken seriously.
    • Community Health Internship
    Students should also gain hands-on experience in diagnosis and management of common health conditions, such as: cases of normal delivery; application of the module for Integrated Management of Childhood Neonatal Illness (IMNCI); management of fever cases; management of gastroenteritis and cholera cases in infants; management of Tuberculosis cases under the Revised National Tuberculosis Control Programme (RNTCP); etc. One can also expect that the CHC/PHCs managed by the medical colleges, would provide high quality service, thus making these centers model units in the area they serve.
  8. New Proposal
    • Network of community
    • Oriented Health Science Institutions
    • Alternative model of Medical Education
    • Fair field trial to access their implement ability
    A model has been developed and proposed by Dr. G.P. Dutta, a veteran medical educationist. The model shifts the fulcrum of medical education from the tertiary care hospital to the community. Under this model, 1 ½ years of the training is centered on a CHC, another 1 ½ years is centered on a secondary care hospital, and the last ½ year’s training is centered on a tertiary care hospital.
    1. The philosophical underpinning of the model rests on the belief that a sustainable and effective health system has to be located in the community. The concept envisages a health system with the following elements: community health planning, community healthcare volunteers, socially–oriented graduate doctors and supervision of the healthcare services by local-self-government institutions and community groups. One element of this holistic model has also been included in the NRHM through the provision of ASHA, who would perform the role of community health volunteers. This proposed model curriculum has been approved by the MCI.
    2. The Task Force has carefully studied the proposed model and finds much merit in it. However, it is observed that it has not been tried out on a pilot basis so far. The success of the model rests critically on the success of the health educators in preparing course material linked to teaching at the decentralized levels of the primary healthcare network in the rural sector. The Task Force feels that all opportunities should be made available to try out this proposed model in different parts of the country.
    3. The Task Force also recommends that the government should encourage pilot studies of this model in government medical colleges. The MCI already having approved the syllabus should have no difficulty in granting registration to graduates from such institutions. On the successful completion of the pilot projects, the application of this model can be extended to privately managed medical colleges also.
  9. Innovation in Medical Education - There is an urgent need for the creation of space and opportunity for experimentation in medical education in the country. Several novel experiments have been conducted - e.g. Kottayam experiment and MCI’s Alternative curriculum; but these were in limited operational conditions. Institutions that have capacity and a socially relevant approach need to be identified and given all support for their experimentation. With the increasing privatization and commercialization of medical education, and the drifting away from primary healthcare to technology-dominated medical care, experiments in primary healthcare are urgently needed, and Dr. Dutta’s decentralized teaching module, deserves consideration.
  10. Any professional course should and does equip the fresh graduates to practice his profession at the level of more common tasks and services.
  11. Teaching Methodology of such course should be problem based and integrate clinical and non – clinical subjects.
ICMCH has assimilated point 6 – 11 above

Training Methodology for graduates of Dr. C.S. Dawn ICMCH, include such practices, (as detailed below) which are among the important recommendations of the Task Force.
  • Skill Oriented examinations – Evaluation include practicals, with specimen, instrument and mannequin.
  • Internal Assessment – Assessment done by both internally and external examiners.
  • Adequate hands on training of fresh graduates. Entire training is hands on training
  • Community Health Internship – Posting at a rural PHC compulsory for the first 3 months.
  • Log Book – Candidates maintain a daily diary throughout their entire training period. This is the heart and soul of the training methodology and the real proof of what the trainee have learnt and how he/she may be evaluated to improve.
Alternative model of Medical Evaluation
The training methodology has been practiced for well over a decade and has imported confidence among graduates leading them to function independently.
Social Education
Like all other professional streams medical graduates need to absorb studies from Psychology, Sociology and Anthropology, to be of better service to the rural financially challenged but a typical behavioured citizens of India. The recommended are fully accepted. ICMCH curriculum would include a chapter of social education in its curriculum from the 2008 session.
Other relevant RCH and Maternal, Child Care pointers in the report
  • 58% of the total population is in the Reproductive age group
  • The quantum of investment in Public Health Expenditure is extremely poor
  • Primary Healthcare services are inadequate and they require a lot of input
  • Private Healthcare Sector provides much larges investments and services
  • Field NGO Sector have shown promising trials
  • The MBBS course as designated by MCI is too theoretical
  • Clinical Experience is obtainable only at PG level
  • Management of Health is a unique, demanding and Complex responsibility
  • Graduates felt they needed improvement – 30% felt they are not confident even under supervision