'Health for all'... still a distant dream?

FUNDAMENTAL CHANGES must occur in the health care delivery system in the medical profession and medical education, to utilise the advances in medicine and technology to suit the health needs of the people. As we control old diseases, new ones appear or some old ones reappear. AIDS and resurgence of tuberculosis, drug resistant malaria and STDs are a few instances. We face many ethical and legal problems due to rapid advancements in medicine and biotechnology. Several medical problems would need proper attention by the IMA and IMC.

The growing population with heavy urban migration is the greatest threat to our country with fragile economy and limited technical facilities. We are 1/6th of the world population with over one billion, and would be 1.5 billion in 2025 and from then on, we will be the most populous country in the world. It would therefore become a Herculean task to deliver health care and other essential services to an unlimited and ever-increasing population. Health statistics of the country reflect the wide gap between needs and resources.

The clinical knowledge and skill of the teachers in medicine should keep pace with advances in science and technology, especially diagnostic advances. There are several tasks that the teacher undertakes as a knowledge and skill disseminator.

No effective monitoring

Teachers are trained in other fields, but not in medicine. At present, there is no effective way of monitoring the teaching- learning process in medicine. The teacher should not act as a didactic pedagogue. Mere lectures keep the students in a passive situation, low receptivity hardly offers any opportunity of checking the teaching-learning process. The important functions of the teaching system like evaluating the course content, teaching methods, competence of teachers and student motivation should all be monitored and evaluated. There is no feed-back mechanism. Most importantly, many become teachers by accident and not by design. It is pertinent to have a separate teaching cadre for those who are interested in teaching medicine as it is a continuous teaching and training programme.

At present, an outdated syllabus is ineffectively taught through outdated methods to an over-crowded classroom, particularly in many private commercial medical colleges, even as they are ill- equipped, under-staffed and devoid of clinical facilities. There are, however, very few private colleges functioning very well and serving as a model for other colleges. The mushroom growth of private medical colleges that blatantly commercialise medical education have become a serious threat to the standard and quality of medical education. Strangely enough, there is no change in the credibility of the private medical colleges, which are making a mockery of medical education. If students turned out of these colleges are recognised on humanitarian ground, one can imagine the repercussions on society.

My own view is that the students should be given more time for study and the incubus of examinations should be lifted from their soul. Let education and examination go hand-in-hand. The students should be taught and tested day-by-day. The teacher, who deals with the students, could easily estimate their progress by scores of tests, which should become an integral part of the teaching process. Teaching, learning and examination actually constitute a unity of functions. The examination system only prioratised memory skill at the expense of other critical skills necessary for a doctor to succeed in life. The newly proposed system of education helps in developing the human resource potential in learners, which makes them responsible for their own learning with quality added growth to their education, resulting in holistic development of students.

At present, teachers continue to train students to diagnose and treat diseases with little emphasis on the way diseases occurred and how they could have been prevented. It is no wonder that doctors, who are products of such training, have reduced primary health centres to mere treating centres.

Newer patterns and techniques of teaching students and also the emergence of distant learning with audio-visual aids is a big boost. Audiotapes, audio and video discs, radio transmission, television broadcasts with a bright future in rural areas, computers, especially personal ones, have created major advances in the storage and transmission of data. Communication between computers has allowed the development of electronic mail, allowing centres around the world to be connected via Internet. Linked with the video, it can transmit images in a short time. All these aids, which are in the transition stage, are not wholly dependable like ``on-line drug therapy'', which should be accepted on the advance of the treating doctor. They should only supplement the fundamental teaching programmes, which should be strengthened as suggested. It is heartening to observe that Prof. K. Anandakannan, V.C. of the Dr. MGR Medical University has enabled the teachers of the senior medical faculty to get computer education and is also attempting to link all medical colleges in the city with tele-medicine facility. The whole state should have this facility in the near future.

An indispensable part of medical education is vocational or career guidance, which has been neglected so far. There should be a guidance programme to enable students to choose a particular area, prepare for it and get placement in it. Every medical college should have a counselling department or cell to guide the young doctor to pursue a particular career, soon after graduation. The Government should conduct periodical medical manpower survey on occupational structure, on the basis of demands of various fields and specialised sectors as well as those needed by particular communities and regions. The data thus obtained will serve to advise medical graduates about promising fields and locations.

It is, therefore, obvious that the methods we employ to train students should be the best available. Unfortunately the education process and career structure do not go together. The basic discontent that students often feel immediately after passing the final examination is that they are hopelessly ill- equipped to start practice independently. In fact, the present system of medical education is training the under-graduate to become specialists. There is a rat race to become specialists and super specialists. Majority of the graduates every year take to post-graduate education, as the only choice open to them. Further, the move by the Medical Council of India to allow non- teaching medical institutions in the Govt. sector to start post- graduate courses, even if they did not offer the undergraduate M.B.B.S course, as a move to create more specialists at a quicker base is rather unfair and unjust to say the least. Far from maintaining standards, the IMC is responsible for the deterioration of standards in medical education at all levels. We need a large number of basic doctors to solve the health problems of our people. Medical education should therefore, be need-based and utility-oriented. It should be judged by its relevance to people's need and its applicability to medical practice. Unfortunately many doctors now are unable to take to general practice due to the high cost of setting private practice. Qualified and trained basic doctors are now a reduced endangered entity. It is leading to the unhealthy trend of practitioners of other systems of medicine and even unqualified persons active in the field resulting in further erosion of modern medical practice.

In medical practice, 80 per cent of diseases are taken care of by family or general practitioners. There is no teaching or training in family medicine at the undergraduate level. Incentives should be offered to doctors who opt for general practice or family medicine for effective community health care. There is no post- graduate training in family medicine at the University level. Family physicians should be trained to contest examinations for necessary certification. It is heartening to note that the IMA college of GPs is introducing ``Diploma in Family Medicine'' to enable doctors to become qualified family medicine specialists. There is no community and population based analysis of people's need to provide relevant and efficient health care system. The discipline of family medicine should be taught in all medical colleges and provide generalist-specialist balance. There is need for a chair of family medicine in every medical college.

The achievement of ``Health for all'' by 2000 has been hampered by unequal access of medical care and preventive services, inefficient health care system, rising costs and rapid growth of physician work force, its mal-distribution and the inappropriate generalist-specialist mix. A major portion of the health budget is spent on training health professionals and we are yet to improve the quality of health care. The allocation of funding for physicians training should be guided by an accurate analysis of health care system requirement, as health care funding should be linked to the needs. There is no need for more medical colleges when our needs are met and when a large number of doctors are unemployed. Adding more and more medical colleges is, therefore, unwarranted and unjustified to say the least. This is particularly applicable to Tamil Nadu. Unemployment allowance should be granted to graduates till they get employed.

Private Medical Service

At present, in India, there are sufficient agencies involved in rendering medical care in addition to the Government but they are all confined to cities and big towns. One major agency is the Charitable Trust, which organises and manages private hospitals in the country. In the second category are hospitals managed by trusts, charitable institutions that are partly financed by the Government. Depending on the Government's financial support, a certain percentage is earmarked for treatment of poor patients in hospitals. In the third category are private hospitals, both managed by private parties as well as joint stock companies. The Apollo Hospital, is an example. In the fourth category are the cooperative hospitals, which are formed by a group of people getting together, each contributing certain amount. Finance and specialist's services are their major problems. Above all, private practice is the major component of medical care in India.

A large number of doctors have been taking up to private practice as a profession, rendering yeoman service to the people. But their service is not freely available in rural areas for obvious reasons. The Government should subsidise general practitioners or family physicians, who deliver essential clinical service and National Health Programme to the people, with the objective to increase quality and reduce the cost of treatment. More and more basic doctors should be encouraged to render service in rural areas by giving incentives by way of subsidies like land at actual cost for building clinics, easy loan for buying equipment and supply of para-medical staff for rendering community health care. If the medical graduates should see rural service as a positive one, they should be able to function with reasonable working conditions and free time, higher pay, promotion, CME programmes, higher studies, professional support including specialists' services, education facilities for children, financial, material and family support. But any health programme will not yield results unless the target groups are identified and priorities set before the work is started. The health care system now is a curious mix of inadequate funds, improper use of resources, without regard to the needs and demands with unevenly mixed up priorities.

Private health care can only be complementary to public institutions and not as a substitute to achieve Health For All, at least in the near future. In India, there should be a ``National strategy for health'' with both long term and short term aims. First, a broad political and social consensus is necessary on this concept. Second, there should be provision of resources at different levels according to set priorities, to take the strategy forward and implement it. Third, periodical surveillance and assessment on the pattern of achievement should be carried out for further improvement. Lastly, the Government should be profession-friendly to execute all health care policies and programmes in coordination with the profession and cooperation of the public. Both should supplement and complement each other and work in tandem for the benefit of humanity.

To achieve the fundamental changes, we require nothing less than a revolution in the health care delivery system from problem- oriented, technology-driven, specialists-dominant medicare to a health care system that is family and community-oriented and focussed on personal service. We require reforms in each of the three areas, the health care system, medical practice and medical education which are interdependent, one complementing the other. In reforming the health care system, the development of physicians work force to carry out and cope with the changes, medical curriculum should be reviewed.

The curriculum should enable the service providers to provide cost-effective, efficient, quality health care through medical practice. So, the reorientation of medical education (ROME) may significantly contribute to producing future doctors with a new role, with new knowledge and skill mix, having attributes of care provider, decision maker, communicator and community advisor that are central to optimum medical practice. It is a constitutional obligation to provide optimal health care to all citizens that would help them to lead a socially and economically productive life. Successful management of professional resources in medicine is more critical than any other resource management. Lacking in latest medical knowledge and skill, especially by specialists and super-specialists is considered equal to negligence by the Chairman of the National Consumer Disputes Redressal Commission.

The World Bank, in its three fold prescription, has urged India to pursue macro-economic growth policy for reducing poverty and providing basic education as a means to good health; re-direct public health expenditure to meet the needs of public health and minimum package of essential clinical services and phase out public subsidy according to needs and priorities; foster competition, diversity and distribution in supply of health services and inputs so as to improve quality and lower costs when ``health for all'' will become a reality. India is the largest cumulative borrower from the World Bank.

Dr. T. M. KUMARASWAMI

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