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Table of Contents
MEDICAL EDUCATION
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 163-167

Primary health care “approach” and medical education: New opportunities for revitalizing the bond


Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India

Date of Submission10-Feb-2020
Date of Decision19-Jun-2020
Date of Acceptance10-Oct-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Mohit P Gandhi
Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_10_20

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  Abstract 

The importance of primary health care (PHC) has once again been reiterated in the Astana Declaration of 2018. PHC is an approach to health systems development rather than just a level of health-care service delivery. Understanding the PHC “approach” is crucial for doctors, across specializations and levels, as they are one of the prominent players in the country's health system. Undergraduate medical education offers an ideal window of opportunity to do so. The medical education policy, time and again, has acknowledged this need and has created mechanisms to fulfill it. The role of departments of community medicine has been kept central in these policy prescriptions. This, in practice, has led other departments to play only a weak role in the teaching and application of PHC. The Medical Council of India's new competency-based medical curriculum, with a renewed focus on integrated teaching, offers fresh opportunities to change this situation.

Keywords: Community Medicine, integrated teaching, pedagogy, re-orientation, undergraduate


How to cite this article:
Gandhi MP. Primary health care “approach” and medical education: New opportunities for revitalizing the bond. Indian J Community Fam Med 2020;6:163-7

How to cite this URL:
Gandhi MP. Primary health care “approach” and medical education: New opportunities for revitalizing the bond. Indian J Community Fam Med [serial online] 2020 [cited 2021 Jan 24];6:163-7. Available from: https://www.ijcfm.org/text.asp?2020/6/2/163/304787


  Introduction Top


The term “Primary Health Care” (PHC) reflexively evokes the image of a rural primary health center, where a doctor is seeing some patients with common complaints such as cough, cold, fever, or diarrhea; a sub-center from where the auxiliary nurse midwife is going out in the village to administer vaccines; an Anganwadi where a worker is weighing babies; and an accredited social health activist who is visiting houses having antenatal women in her area. However, the classical text of the Alma Ata declaration and its nuanced interpretations posit PHC as an “approach” to overall health systems development, rather than just a level of care with a set of services provided through a team of peripheral workers.[1],[2],[3] Thus, the principles of PHC apply as much to the functioning of a medical college (MC) and hospital as to a primary health center and its sub-centers.

The relevance of PHC for India has been well acknowledged in the health policy documents across decades.[4],[5],[6],[7],[8],[9] The importance of the approach has once again been re-iterated in the Astana Declaration which calls it “a cornerstone for a sustainable health system for universal health coverage and health-related sustainable development goals.”[10] One of the important requirements so as to bring this “approach” into practice is to make the doctors, who are the key functionaries at different levels of the health system, understand the underlying concept in its most comprehensive form.[11] Undergraduate (UG) medical education offers an ideal window of opportunity to do so.


  Adoption of Primary Health Care in Undergraduate Medical Education Top


Recognizing the need to include community and preventive aspects in the training of “basic doctors,” the Bhore Committee recommended the establishment of departments of preventive and social medicine (PSM) in every MC.[4] The departments were supposed to give a social perspective to health problems and health practices; knit together concepts and methods of public health with those from other related medical disciplines; and interact with teachers of other disciplines to provide a social dimension to their teaching.[12]

In the latter half of the 1970s, a scheme for Re-orientation of Medical Education (ROME) was launched. The objectives of ROME were to give rural orientation to the faculties, students, and interns and to channelize the potential of MCs to improve health-care services in rural areas.[13] Each MC was expected to take administrative charge of three primary health centers where medical students and interns would be posted.

Besides this, the General Medical Education Regulation (1997) stated that “at the end of the undergraduate program, the medical student should be able to recognize “health for all” as a national goal…”[14] The curriculum prescribed for community medicine (CM) under the regulations included teaching of “principles and components of PHC and the national health policy to achieve the goal of “health for all”….”.[14] The Medical Council of India's Minimum Standard Requirements for the MC include provision for a rural and an urban health training center under the academic control of the dean.[15]

While several MCs such as CMC Vellore and MGIMS Wardha have been engaged in orienting their medical students on PHC, looking at the larger picture, there are significant challenges.


  The Challenges Top


Despite the pronunciations in the policy and curriculum, medical education has remained unresponsive to the PHC needs of the country. Graduates are, still, more suited to work in hospitals than in communities.[16] There is a predilection for clinical specialization, “latest technologies,” and urban practice.[17] Twenty-four percent (8286/33,968) of sanctioned positions of doctors at primary health centers are vacant, despite more than 60,000 medical seats in the country.[18] Doctors, in general, are seen to be bringing medical bias in public health planning.[19] Research topics selected by the faculty and their postgraduation (PG) students are not found to be innovative or locally relevant.[20] Often, they are found to be influenced by international funding.[21],[22] With due regards to exceptions, doctors continue to remain techno-centric. All of these lie diametrically opposite to the position of PHC.

To ensure that medical students come out adequately oriented in PHC is not the responsibility of the departments of CM alone. However, creation of a separate PSM department led to relegation of the teaching on preventive aspects by faculty of other subjects.[12] In most MCs, the responsibility to co-ordinate ROME was given to the PSM department. This made ROME a “PSM activity” in which other specialties did not take much interest.[14],[22] The case is no different even at present when the activities at rural and urban health training centers, where they actually exist, are almost exclusively managed by the department of CM. Other departments remain busy in the hospital.

Preliminary findings from an ongoing larger study involving the departments of CM of four MCs inform that integrated teaching has been happening in the lecture halls and in the wards. Institutions, that have incorporated community orientation camps in their UG curriculum, also engage different specialty departments to demonstrate clinico-social history taking at household level. The institutional ethos of holistic health and a supportive management are the enabling factors for such integrated teaching. Still, these activities occur only infrequently, ranging from once a month to once a year. The faculty find it difficult to resolve differences between “public health guidelines” and “clinical protocols,” for instance, in the management of neonatal and childhood illnesses. Divergent disciplinary orientation and academic arrogance are the impediments to such reconciliation. Senior faculty who have themselves experienced an integrated pedagogy and who have been able to develop a perspective beyond “the clinical” do justice to such sessions. However, over time, as hospitals have become increasingly complex, their participation in these activities has reduced. They have started sending junior faculty or even PG students, which does not serve much purpose. Given their clinical workload, they see these activities as “additional tasks.” And sometimes, things do not happen just because one department is “instructing” the other rather than establishing a dialog.

The departments of CM, in general, may themselves not have been able to make the contribution expected of them toward orienting medical students in PHC. There may be multiple factors responsible for this. The possible actors in this process include the medical students themselves, who have to be receptive; the CM faculty, who have to absorb and exude the essence of PHC, and remain motivated; the college management, which has to make resources available to the department (such as staff, vehicles, and access to field); the regulatory body, which has to be more flexible with regard to curriculum, pedagogy, and assessment methods; and the professional system in which the medical student would ultimately work. However, even in the best case scenario, the CM departments cannot attain this objective if the other departments of the MC carry on their business as usual.

Recounting their experience of visiting seven MCs in the country, Narayan et al. writes, ”Where reorientation was seen as the primary responsibility of one department, or was projected as having to support one departments' training programme…the significance of the reorientation attempt or the enthusiasm of the faculty was being negatively affected”.[21]


  New Opportunities Top


In 2018, the Medical Council of India has revamped and repackaged the UG medical curriculum by involving subject experts from different MCs.[23] A list of topics for each subject and a set of competencies for each topic have been put forth along with suggested teaching–learning and assessment methods. Besides, the long talked about “integrated teaching” has been operationalized. For each competency, it mentions the subject(s) that needs to be integrated, in a vertical and/or horizontal framework. Data compiled from the pages dedicated to CM in the curriculum document show that there are around eighty competencies across fourteen subjects which would require integration with CM [Table 1]. Moreover, a similar number of competencies in CM would require integration with nine other subjects [Table 2].
Table 1: Number of competencies in other subjects that would require integration with Community Medicine

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Table 2: Competencies in Community Medicine that would require integration with other subjects

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The faculty from different departments are expected to collaborate in the lesson planning and, wherever necessary, to also remain present when these competencies are actually being developed in the students (p35, Vol. II).[23] In either case, it calls for a very close professional interaction between the faculty of CM and those from other disciplines on an equal footing. The two mindsets, one focused on individual patient's disease and the other concerned more about population health, will have to per force sit together and listen to each other. For instance, when the department of obstetrics and gynecology invites faculty of CM to plan/develop competency to “counsel in a simulated environment, contraception, and puerperal sterilization” [Table 1], OG 19.2], there is an opportunity to discuss population control as a developmental issue. Or when the department of CM requests faculty of pediatrics to plan/develop competency to “describe and discuss the importance and methods of food fortification and effects of additives and adulteration” [Table 2], CM 5.8], there is an opportunity to talk about the long-fought struggle against breast milk substitutes.

While the Medical Council of India's renewed focus on integrated teaching should be fully tapped, other mechanisms of professional interactions between different departments of the MC should also be activated. They should better engage in delivering clinical services in the outreach, and should collaborate for community-based research. Participating in inter-departmental discussion platforms such as clinico-pathological conferences and involving other departments in clinic–social case presentations can also expose the faculty to each other's perspectives. Organizing continuing medical education sessions on the concept of PHC approach and on ROME may be a good starting point.

The fusion of two different worldviews (medicine: health; patients: population) will enrich both groups of faculty. Especially for the faculty of CM, this will be a stimulus to re-examine and renew their own understanding of the concepts, principles, and operationalization of PHC. Overall, this is an opportunity to revitalize the bond between medical education and PHC, which will help in sowing the seeds of comprehensive PHC approach in the minds of the medical students. Such evolved medical graduates will be a significant contribution of the medical education system toward realizing the ambition, as laid out in the Astana Declaration, of achieving “health and well-being for all, leaving no one behind.”[10]

Acknowledgment

The author is grateful to Prof. Ritu Priya (Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi) for her continuous guidance and critical comments on this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization- United Nations International Children's Emergency Fund. Report of the International Conference on Primary Health Care (Alma-Ata, USSR, 6-12 September 1978). Geneva: World Health Organization; 1978. Available from: http://apps.who.int/iris/bitstream/10665/39228/1/9241800011.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 1
    
2.
Tarimo E, Webster E. Primary Health Care Concepts and Challenges in a Changing World: Alma-Ata Revisited. Division of Analysis, Research and Assessment, WHO; 1994. Available from: https://apps.who.int/iris/bitstream/handle/10665/62650/WHO_ARA_CC_97.1.pdf?sequence=1&isAllowed=y. [Last accessed on 2019 Dec 27].  Back to cited text no. 2
    
3.
Priya R. State, Community and Primary Health Care: Empowering or Disempowering Discourses? In: Prasad P, Jesani A, editor. Equity and Access: Health Care Studies in India. 1st ed. New Delhi: Oxford University Press; 2018. p. 25-49.  Back to cited text no. 3
    
4.
Government of India. Report of Health Survey and Development Committee (Bhore Committee). New Delhi: Government of India; 1946.  Back to cited text no. 4
    
5.
Narain R. Towards a New Health Policy. New Delhi: Department of Family Welfare; 1978.  Back to cited text no. 5
    
6.
Indian Council of Social Science Research/Indian Council of Medical Research. Report on Health for All: An Alternative Strategy. Pune: Indian Institute of Education and Indian Council of Social Science Research; 1980.  Back to cited text no. 6
    
7.
Ministry of Health and Family Welfare. National Health Policy 1983. New Delhi: Ministry of Health and Family Welfare, Government of India; 1983. Available from: https://www.nhp.gov.in/sites/default/files/pdf/nhp_1983.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 7
    
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Ministry of Health and Family Welfare. National Rural Health Mission: Framework of Implementation (2005-2012). New Delhi: Ministry of Health and Family Welfare, Government of India; 2005. Available from: https://nhm.gov.in/WriteReadData/l892s/nrhm-framework-latest.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 8
    
9.
Ministry of Health and Family Welfare. Report of the Task Force on Comprehensive Primary Health Care Rollout. New Delhi: Ministry of Health and Family Welfare, Government of India; 2015. Available from: http://nhsrcindia.org/sites/default/files/Report%20of%20Task%20Force%20on%20Comprehensive%20PHC%20Rollout.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 9
    
10.
World Health Organization- United Nations International Children's Emergency Fund. Declaration of Astana: Global Conference on Primary Health Care (Astana, Kazakhstan, 25-26 October 2018). Geneva: World Health Organization; 2018. Available from: https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 10
    
11.
Ramalingaswami P, Shyam A. Perception of Primary Health Care by Medical Students. In: Proceeding of the Conference Held at Indian Council of Medical Research. 1980 Apr 21-23; New Delhi. New Delhi: Indian Council of Medical Research; 1980. p. 216-23.  Back to cited text no. 11
    
12.
Banerji D. Social orientation of medical education in India. EPW 1973;8:485-8.  Back to cited text no. 12
    
13.
Panackel J. Medical Education in India: In Search of Relevance. [Master of Philosophy dissertation]. New Delhi: Jawaharlal Nehru University; 1986.  Back to cited text no. 13
    
14.
Medical Council of India. Regulations on Graduate Medical Education, 1997. New Delhi: Medical Council of India; 1997. Available from: https://www.mciindia.org/CMS/wp-content/uploads/2017/10/GME_REGULATIONS-1.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 14
    
15.
Medical Council of India. Minimum Standard Requirements Regulation, 1999. New Delhi: Medical Council of India; 1999. Available from: https://www.mciindia.org/CMS/wp-content/uploads/2017/10/Minimum-Standard-Requirements-for-150-Admissions.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 15
    
16.
Rangan S, Uplekar M. Community health awareness among recent medical graduates of Bombay. Natl Med J India 1993;6:60-4.  Back to cited text no. 16
    
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Bhat S, D'souza L, Fernandez J. Factors influencing the career choices of medical graduates. J Clin Diagn Res 2012;6:61-4.  Back to cited text no. 17
    
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Ministry of Health and Family Welfare. Rural Health Statistics (2016-17). New Delhi: Ministry of Health and Family Welfare, Government of India; 2017. Available from: https://data.gov.in/catalog/rural-health-statistics-2017. [Last accessed on 2019 Dec 27].  Back to cited text no. 18
    
19.
Bajaj J. Education in Health Sciences: Relevance and Excellence. In: Medical Education and Health Care: A Pluridimensional Paradigm. Shimla: Indian Institute of Advanced Studies; 1998. p. 1-23.  Back to cited text no. 19
    
20.
Lal S. Scenario of Postgraduate Medical Education in Community Medicine in India. Indian J Community Med 2004;29:56-61.  Back to cited text no. 20
  [Full text]  
21.
Narayan R, Narayan T, Tekur SP. Strategies for Social Relevance and Community Orientation: Building on the Indian Experience. Bangalore: CHC, SOCHARA; 1993. Available from: https://www.sochara.org/uploads/researchuploads/_Strategies%20for%20social%20relevance.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 21
    
22.
Qadeer I, Nayar KR. Politics of pedagogy in public health. Soc Scientist 2005;33:47-75.  Back to cited text no. 22
    
23.
Medical Council of India. Competency-Based Undergraduate Curriculum for the Indian Medical Graduate. New Delhi: Medical Council of India; 2018. Available from: https://www.mciindia.org/CMS/wp-content/uploads/2019/01/UG-Curriculum-Vol-II.pdf. [Last accessed on 2019 Dec 27].  Back to cited text no. 23
    



 
 
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Abstract
Introduction
Adoption of Prim...
The Challenges
New Opportunities
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