MEDICAL AND PARAMEDIC EDUCATION IN INDIA: NEED FOR MAJOR REFORMSDr Shyam Ashtekar

AISSC. Ahmadabad, 22 Nov 2012

OVERVIEW : HEALTH HUMAN RESOURCES AND RELATED ISSUESSome Ground Realities

HHR IN VARIOUS COUNTRIES

Country doctors Nurses+MW Pharmacists lab W Other HWsIndia 0.6 1.3 0.6 0.02 1.13China 1.6 1.03 0.3 0.02 0.93Cuba 5.9 7.4 0.07 2.75USA 5.5 7.7 0.7 2.3 16.1UK 1.7 5.6 0.6 0.34 3.79

Table 1: HHR density in some countries per 1000 pop

Dr Thamma Rao: NHSRC as per endnote, based on WHO 2007

HHR DENSITY IN INDIA

DOCTORS IN A DISTRICT STUDY (1: 634P)

04/11/2023 5

DOCTORS IN NASHIK CITY

04/11/2023 6

A) Gen Practitoners

BAMS

Homeopaths#

MBBS

degree not Avialble

BUMS Yunani

B) Dentists

C) Specialists

Ob-Gynec

Child sp

MD Ayurveda

Orthopedic sp

General Surgeons

Radiologists

Eye specialists

gen Physician

Pathologists

Anesthetists

Psychiatrists

ENT sp

Skin specialist

Super specialty

0 200 400 600 800 1000 1200 1400 1600 1800

1622

1250

153

121

91

7

350

1106

200

140

100

87

85

83

80

75

65

65

50

26

25

25

DOCTORS IN NASHIK DISTRICT

PG-M

med

MBB

S

PG-A

YU

BAMS

Homeo

path

Unani

Dents

its

Other

doc

s'0

200

400

600

800

1000

1200

1400U-Pub

U-Pvt

R-Pub

R-Pvt

OVERVIEW OF MEDICAL INSTITUTIONS IN INDIA

355 MBBS colleges, nearly UG 43890 seats 161 belong to Govt, with about 20000 UG seats 194 are Pvt colleges, with 23900 UG seats National Eligibility-cum-Entrance Test for MBBS

Course (NEET-UG ) will be held from  2013 NEET should take care of entry level corruption,

multiple tests etc.

URBAN-RURAL HHR GAP 28% of the country’s population is urban (Census

of India 2001)". Going by density of health workers per 10,000

pop, urban HHR density is 4 times that in rural areas.

Post graduate doctors are mostly in urban Pvt sector, so also the dentists and Ayurveda GPs. (My study of Nashik district the distribution of doctors)

One can not expect an equal HHR proportion in Urban-Rural since most specialists are city-bound. BUT basic doctors/Family Physicians need to be well distributed.

HHR- THE 70:30 PRIVATE-PUBLIC DIVIDE Majority (70%) of HHR is in the private sector

in both urban and rural areas. In my study of Nashik district barely 10%

doctors are in the public sector. (Staggering 90% in Pvt Sector including unregistered doctors)

Around 50% of the nurses & midwifes are in public sector.

EROSION OF PRIMARY CARE IS NOT GOOD

In the medically advanced states and metros, we see specialists occupy the apex of medical care, and GPs are being pushed out.

Primary care, in the GP domain, may get reduced to simply coughs n colds, diarrhea n dysentery, aches and fevers!

The ultimate erosion of primary care will escalate medical interventions, raise unit costs of care, worsen availability of physicians and overload hospitals

RISE OF THE SPECIALIST About 45 specialties are now listed by MCI : diploma

(DNB), MD (29) MS (5), DM(12), MCh(10) Nearly 50% (20000+) MBBS graduates can get PG

seats. Another 30% can get CPS diplomas..leaving 20% at grad level!

The role and share of specialists in outpatients and hospitals is ever increasing, the generalists are losing ground (The grand old Gen Surgeon is on the last leg)

Even in super-specialists, we have both physician and surgeons. Decision making is increasingly complex for ‘clients’!

Costs are rising, but outcomes are also generally better!

Therefore the medical pyramid is becoming top heavy!

HEALTH VS MEDICALIZATION Are we giving up ‘health’ for medicine? For instance BP can be prevented and

detected early, and not just treated ! Is the physician/cardiologist interested?

Health promotion and prevention are taking back seats or even getting medicalised (the great vaccine boom is a proof)

Increasing ‘deconstruction’ of specialties is losing the holistic view if life and body

PUBLIC VS PRIVATE MEDICAL EDUCATION Medical education, once the pride of the Govt and local

bodies, is now equally shared between Pvt and public. In southern states, the expansion of care is mainly

because of pvt owners. The quality of medical education has suffered directly

and indirectly with rise of Pvt colleges, first because they sucked teachers from public institutes and second because they manipulated at many levels including the MCI visits (the infamous Ketan Desai case)

The student has to pay stiff prices esp for PG seats. This has further tilted the elitist bias in medical education.

PATHY ISSUES: MODERN MED(MM) & AYURVEDA

Ayurveda (also Siddha & Unani) has taken the shudhha option some 3 decades back, in order to protect the system from the MM

However, most AYUSH graduates practice MM later For this they claim they have learnt MM in their ‘syllabus’ and

college hospitals; which they somewhat. But there is no subject examination for MM medicine,

pharmacology, pathology etc. So this claim is spurious. It is quite welcome that Governments employ them in PHC-CHCs.

But there is no formal training or assessment for MM use. The AYUSH board can not authorize them for MM use, nor

MCI/state council stop them (Police can lodge a case) So we now stand to lose both the scientific practice of AYUSH and

the legal cover for integrated practice. The issue can not be solved in courts of law (SC has ruled against use of the ‘other’ pathy)

The impasse has to be solved by a consensual central amendment.

THE PATHY ISSUE: MM & HOMEOPATHY

Homeopathy is an entirely different approach based on like cures like (symptoms in the patient need to be matched to medicines that produce similar symptoms in normal doses..the same medicine works only in nano doses)

Allopathy works on principles of diagnosis based on symptom--How can then a homeopath use allopathy, is it scientific?

THE CLASH OF PATHY INTERESTS But the major clash is for sharing the health care

cake MM community wants to keep the right to use MM. AYUSH doctors want to use MM remedies to

survive in the health market The SC has rued against this ‘cross pathy’ BRMS/BRHS courses seem to be a small way out .

But AYUSH doctors can not take even BRMS!

HHR NEED:30 LAKH POP DISTRICT AND INDIA

Table 3: HHR requirements for a 30 Lakh district and projection for India

The District Model IndiaHHR for 30L dist Rural Urban+

Med college

Total pop per unit

Country need

HLEG 2011**

Actual shortfall *

(A) Beds (public sector) 1500 1900 3400 882 1360000

(B) HHR-category-doctorsSSP 0 50 50 60000 20000 209091 676756Specialists 240 350 590 5085 236000 NAMM-MO 280 200 480 6250 192000 417119Ay MO/BRMS 410 410 820 3659 328000 314547 196488Dentists 100 100 200 15000 80000 22962 74649Admin MOs 10 10 20 150000 8000Total doctors 1040 1120 2160 1389 864000 896206 +32206(C) Other HWsNurses+Midwives 2120 1110 3230 929 1292000 11 Lakh 823588 468412Other PM 820 800 1620 1852 648000 23276 624724Ward Asst etc 1860 1800 3660 820 1464000Support staff 660 600 1260 2381 504000Total of other HWs 9770 307 3908000 20 Lakh 846864

All HWs 11930 251 4772000 1743070 3028930ASHAs 3600 833 1440000 9000000 +7560000(+ plus sign shows surplus HHR) ** HLEG makes different assumptions,. HHR is state bound-India pool is no help

NATIONAL HEALTH POLICY (NHP) 2002 RECOMMENDS

Extending public health services(..) to AYUSH doctors

Expanding the pool of General Practitioners to include a cadre of licentiates including Indian systems of Medicine and Homoeopathy is recommended in the policy in order to provide trained manpower in underserved areas

..contract employment for such doctors.

NHP 2002 CONTEXT

4.8 EDUCATION OF HEALTH CARE PROFESSIONALS 4.8.1.1 In order to ameliorate the problems being faced on

account of the uneven spread of medical and dental colleges in various parts of the country, this policy envisages the setting up of a Medical Grants Commission for funding new Government Medical and Dental Colleges in different parts of the country. Also, it is envisaged that the Medical Grants Commission will fund the upgradation of the infrastructure of the existing Government Medical and Dental Colleges of the country, so as to ensure an improved standard of medical education.

4.8.1.2 To enable fresh graduates to contribute effectively to the providing of primary health services as the physician of first contact, this policy identifies a significant need to modify the existing curriculum. A need-based, skill-oriented syllabus, with a more significant component of practical training, would make fresh doctors useful immediately after graduation. The Policy also recommends a periodic skill-updating of working health professionals through a system of continuing medical education.

NHP 2002 ON NURSING PERSONNEL..

4.10.1.1 In the interest of patient care, the policy emphasizes the need for an improvement in the ratio of nurses vis-à-vis doctors/beds. In order to discharge their responsibility as model providers of health services, the public health delivery centres need to make a beginning by increasing the number of nursing personnel.

MCI & NCHHR

The proposed NCHHR has been returned by the Cabinet for some reasons

Was NCHHR only for Modern Medicine? Will it permanently outcaste AYUSH as a third

rate system? Will it encroach on rights of state to remodel

their medical education?

HLEG CONTEXT

4 TIER HEALTH CARE: A DISTRICT MODEL

Tertiary Hospitals

District & urban ward Hospitals (>100 beds)

30 bed Rural Hospitals

Pri

mary Health Centers (30000 pop)

Sub-centers (3000 pop) with paramedics or BRMS/AYUSH docs

THE CURRENT HHR PYRAMID

Allopathic

doctors/ specialis

ts

Informal providers (with due training)

Nurses & paramedi

cs

AYUSH doctors

THIS IS ALSO A STATE SUBJECT Medical & paramedic education is a state subject The states have to invest in and redesign the

programs for state needs, broadly keeping with national guidelines and councils

A RADAR OF ISSUES AND REFORMS

1 Expanding Med Ed to deficit states

2 Courses for village doctors

3 Courses for paramedics

4 District based umbrella institutions

5 Common Platoform for Healing systems

6 Mainstreaming AYUSH doctors with bridge courses7 Expanding Nursing education

8 Syllabus & Learning reforms incl ODL, PBL

9 Revisit NEET

10 Integration of Health Services & Med Education

11 Continuing Medical Education

12 Pvt medical Education-cost control & Transparency

0

5

10

1 MEETING THE DEFICIT OF MED EDUCATION IN SOME STATES

DOCTOR DENSITY IN INDIAN STATES 2001

HHR INSTITUTIONS IN INDIAHHR Institutions & Availability (NHP 2008 NHSRC HHR Division)Institute Numb

erAnnual uptake

Availability of HHR HHR: pop ratio

1. Medical Colleges 289* 32,815* MOs 2,15,199 Spec. 1,52,437

1:1,667 Population-India

2. Dental Colleges 282 22,650 Dentists 14,499 1:35 Lakh – Bihar; 1:18,812 - Pondicherry

3. AYUSH Institutions 477 27,265 Drs. 70,202 1:798 Population - India

4. Nursing Schools 1,620 62,647 Nurses 6,90,564 1: 264 population – India; 1: 100-200 - Europe

5. ANM Schools 329 6,502 ANMs 5,24,283 1,42,655 - 2nd ANM; 43,966 - New SHCs

6. Health Worker - Male

102 5,334 2,28,946 No Registration from Council

7. Pharmacy - Degree 241 13,400 1,25,915 India 1 : 1,840;

Phramacy: Diploma 523 31,543 Europe 1 : 2,300

9. Lab Technician 97 2,193 1,44,990 No Registration Council10. Radiographers 33 410 36,628 No Registration Council11. Ophthalmic Tech. 41 426 46547 No Registration CouncilTotal 4034 2,05,185 21,04,650Curtsey: DR Thamma Rao & NHSRC, * based on older estimates (new figure is 355 & 43000)

DOCTORS: THE DISTRIBUTION GAP IN STATES (CENSUS 2001 ESTIMATES)

Punjab has a high density (8-23 / 10000) of doctors,

J&K, Sikkim,Haryana, Maharashtra, Karnataka,WB, Uttaranchal and Goa (6-8 docs/10000) are next.

Then come MP, UP, Mizoram, TN (?), Kerala. The last group has (4-6 docs per 10000) has

Orissa, Bihar, Zarkhand, Chhattisgarh, Rajasthan, Assam, Arunachal and surprisingly Gujarat.

This picture nearly conforms to the number of medical colleges in each state except Gujarat.

Guj, Mah. AP, TN, Kar, Ker together have 60% MBBS medical colleges and 62% of medical seats.

2 COURSES FOR BASIC DOCTORS/VILLAGE DOCTORS

THE FAMILY PHYSICIAN The irony is that Family medicine is also

becoming a PG course, to be done after MBBS. This will escalate costs of care in primary sector

A 3 year course could have fit in well, with CME and supply of Essential Drug List

The MCI/NCHHR (National Council of Health Human Resources) is trying to distance itself from realities of India by neglecting village needs and an elisitist neglect of AYUSH.

THE RURAL PROBLEM

Those who we call doctors, don’t like to go to rural areas.

Those who work as doctors in rural areas, we

don’t call them doctors, but quacks! In many states, this is the quintessential

problem in health care!

THE SHORT MEDICAL COURSE-BRMS

BRMS (Bachelor of Rural Medicine & Surgery) Recently MCI has supported this Though now it is BRHS (H for Health) It will be launched in district hospitals.

THE QUACKS (INFORMAL PROVIDERS)

The MCI estimate of quacks can be around 25 lakh (on what basis is not known). They far outnumber the official doctors.

MCI lodges occasional complaints against quacks but also admits that they are there because MBBS doctors are unwilling for working in rural areas.

Their practices are quasi-scientific they get some hands-on-training and use some books.

Viewed from the people's need angle, quacks have served a crying need.

3 COURSES FOR PARAMEDICSIndia needs to train millions of health workers of different types, accredit them and raise their working standards and lives!

IT IS NOT JUST DOCTORS AND NURSES!

1. Allopathic physicians/surgeons -2. Health Professional (except nursing)3. Dental Specialists - 4. Ayurvedic physicians/surgeons; 5. Homeopathy physicians/surgeons ; 6. Unani physicians/surgeons -7. Nursing Professionals - 8. Nursing Associate Professional -9. Sanitarians -10.Midwives - 11.Pharmaceutical Assistants- 12.Medical Assistants - 13.Medical Equipment Operators; 14.Life Science Technicians (Lab technicians); 15.Dieticians & Nutritionists -; 16.Optometrists -17.Dental Assistants; 18.Modern Health Associate Professional (except nursing)19.Health Professional except Nursing -20.Traditional Medicine Practitioners -21.Faith Healers -22.ASHA and Anganwadi workers

THE GAP IN PARAMEDIC SECTORCategory Required Available Additional

Required

Pharmacists (Allopathy)

1,36,869 20,967 1,15,902

Lab. Technician 1,36,869 12,904 1,23,965

Radiographer / DRA 37,681 1,867 35,814

O T Technician 46,563 NA 46,563

Ophthalmic Technician

66,478 NA 66,478

Physiotherapist 66,478 NA 66,478

Source: Dr. D. Thamma Rao, Public Health Foundation of India, New Delhi

ALLIED HEALTH COUNCIL

Paramedic councils will now be formed in states and some system of paramedic education flow

There are many contentious issues of law (can they ues medicines?), education policies, professional councils, and turf battles like between the eye surgeon and ophthalmologist

4 EXPANDING NURSING EDUCATION

NURSES IN INDIA Nurses follow the doctors' density map About 56% registered nurses & midwives are in

the 5 southern states (Maharashtra, Karnataka, Kerala, TN and AP).

Goa and NE states except Assam also have high density of nurses.

50% Nurses are in the public sector, mainly because nurses prefer Govt sector as a better employer! The small size units are unwilling to pay and provide security to nurses.

5 COMMON PLATFORM FOR HEALING SYSTEMS

COMMON PLATFORM FOR MODERN MEDICINE & AYURVEDA

The district hospital should serve as a common meeting platform for 2-3 pathies

The health subcenter can serve both MM & Ayurveda services, with trained paramedics and doctors of ‘basic’ category

Meaningful research and conflict-resolution can happen only on such platform.

6 MAINSTREAMING AYUSH DOCTORS WITH BRIDGE COURSES

A Homeopath in UP’s Rural Hospital-OPD 2012

MAINSTREAMING AYUSH DOCTORS

Many states have posted AYUSH doctors in public health centers and hospitals-A welcome step

But there is no formal induction of MM, no legal cover for MM use

We need bridge courses in flexi formats & rigorous tests for use of select MM remedies before they are posted

This bridge requires legal cooperation of all councils-calls for a political solution via parliamentary

7 RAISING A DISTRICT BASED UMBRELLA INSTITUTION FOR MEDICAL & PARAMEDIC EDUCATION

DISTRICT BASED UMBRELLA INSTITUTE FOR MED-ED

A unit of 30 lakh should be treated as a district

Covert the district hospital (500 beds) into a UG medical college (PG in select centers)

Will also have a BAMS college & hospital unit, with a Homeopathy OPD & institute

Nursing college for ANM-GNM Institute for Paramedics for hospitals and

community Other allied health staff like sanitary

inspectors

8 SYLLABUS & LEARNING REFORMS INCLUDING FLEXI LEARNING, PROBLEM BASED LEARNING, EBM ETC

REFORMS IN MEDICAL EDUCATION

Med Ed is increasingly biased for PostGrad, didactic, bookish and theoretical, rote based, exam oriented this is counter productive!

We need a layered education, ensuring we get enough basic doctors at level1, rather than only PGs who will only work at higher end.

We need pedagogic reforms, use of Problem based learning, flexi learning methods, strong practical component

Consider Bi-Lingual medium to ensure community links, accountability, ethics,

Promote preventive approaches, Evidence Based Medicine and research orientation.

A PAST STUDENT OF MBBS SAYS ABOUT HIS EDUCATION No student can straightway start medical work after

this course (he is from a renowned Mumbai Municipal college). There is no such capacity building.

The syllabus and books are huge, but students have complied notes and this has replaced many biggish books..Parks-PSM for instance

The main task from 2nd MBBS is the Entrance test for PG, run by pvt coaching classes. They offer combo packs for two years, sponsor student gatherings etc.

So last 6 semesters and internship are spent in ET, internship is all managed..none is serious about it!

A PAST STUDENT OF BAMS SAYS ABOUT HER EDUCATION

The teachers ask us to read ‘pharmacology’ while they deal with dravyagunavidbyan..which itself is quite huge

But there is no pharmacology examination as such.

Hospital training is poor No counseling about what to do after BAMS

course Every one is going for PG program.

9 REVISIT NEETIs the PG entrance exam reducing the graduate medical program to a formality before PG?

NEET FOR UG

NEET (National Entrance Eligibility Test) for undergraduates has helped to ‘optimize’ entry process and level playing field across states, and chastened the pvt medical colleges

However 8 high-courts have stayed the NEET (UG or PG)

COMMON ENTRANCE TEST PG

PG CET/ PGNEET turned the entire medical college training program into another entrance exam.. this is the biggest problem.

We need to detoxify the medical training from mindless PG NEET competition. HOW do we do this is a big problem!

10 INTEGRATION OF HEALTH SERVICES & MED EDUCATIONSegregation has caused unfavorable terms for doctors in the services as compared to med-ed

INTEGRATE MED-ED AND HEALTH SERVICES

The segregation of MedEd (DMER) and Public Health dept has created a new varnashram in health care sector, the former offers better pays, better working conditions and urban life. Health services dept is getting a bad deal!

11 CONTINUING MEDICAL EDUCATION (CME)

CME

CME is just taking off, but it is not well organized

The syllabus and implementation has to be planned and learning resources widely available

Evaluation/accreditation is a distant issue, CME for other pathies and nurses is also

necessary

OPEN SOURCE FOR HEALTH INFO

We need a source of authentic health info in All Indian languages.

This can be an open source for primary care, paramedics, consumers and students.

We need diagnostic algorithms to help decision making, decide protocols

More authors, institutes, and donors need to contribute.

Medical colleges, students, teachers, illustrators can help!

Wikipedia is not very strong movement in Indian languages—for various reasons

OUR WEBSITES FOR PRIMARY HEALTH CARE IN MARATHI AND HINDI

http://www.arogyavidya.net/arogyavi/

Already launched 20 months..clocked 1.4 million visits (2000 daily)

Need support for sustenance and development

http://www.bharatswasthya.net/#

Part-1 to be launched in 2-3 weeks

Need help by way of funds, contributors, videos, advsetisements etc

12 PRIVATE MEDICAL EDUCATION-COST CONTROL & TRANSPARENCY ISSUES

PVT MEDICAL COLLEGES

A difficult customer, is it a solution or problem?

Quality of med Ed herein is questionable, barring some places.

Costs to students are high and hence it is helping only some rich families (PG premium is about 50 L+). This is perpetuating ‘dynasty’ hospitals

NEET is only one way of regulating entrance Regulation in Pvt medical sector has proved

to be very difficult-given the money power and collusion of MCI

?

SUMMARY

1 Expanding Med Ed to deficit states

2 Courses for village doctors

3 Courses for paramedics

4 District based umbrella institutions

5 Common Platoform for Healing systems

6 Mainstreaming AYUSH doctors with bridge courses7 Expanding Nursing education

8 Syllabus & Learning reforms incl ODL, PBL

9 Revisit NEET

10 Integration of Health Services & Med Education

11 Continuing Medical Education

12 Pvt medical Education-cost control & Transparency

0

5

10

THANKS

Dr Shyam AshtekarBharat Vaidyaka sanstha

& Sadiccha Trust

21 Cherry Hills society, Anandwalli, Nashik 422013

Website: http://www.bharatswasthya.net/#

Cell 91-9422271544