Deptt. of S.P.M., Pt. BDS PGIMS, Rohtak
Research question: To what extent the faculty of Community Medicine is aware of recent strategies and development of RCH Programme and their involvement in training and research endeavours.
Objectives: 1. To orient the faculty of Community Medicine on newer developments under RCH Programme. 2. To incorporate RCH strategies into the curriculum of UG's and PG's.
Study design: Cross-sectional.
Participants: Faculty of Community Medicine (Lecturers, Assistant Professors, Associate Professors and Professors) of 52 different Medical Colleges in the Country.
Study variables: Status of training, orientation, involvement in training, continuing education and research endeavours of RCH and areas not included in UG's and PC's programme.
Outcome variable: Faculty trained, areas and strategies of RCH included in the curriculum of UG's and PG's. Methods: The information on current situation of training on RCH was captured through, structured schedule, open discussion brain storming session, group work and informal discussions with faculty members during two days orientation workshop. Plan of action developed by group work reflected the intention of incorporating the strategies into the UG's and PG's programme. Feedback obtained through follow up activity provided useful data on strategies incorporated in RCH training programme.
Results: 256 faculty members of 52 Medical Colleges of the country were oriented on RCH strategies programme. Over 80% of institutions have incorporated the RCH programme and its strategies into the undergraduate programme and 16-20 hours are being devoted for Lecture discussion; demonstrations and observational visits in the areas of concept of Paradigm shift, Community needs assessment, Gender issues, Adolescent health, Decentralization, Subcentre and PHC action plans and client satisfaction and quality of care, RTI/STI and communication strategies under RCH. During final evaluation, theory papers cover atleast one long question and short note and viva voce and practical exam also covers adequate elements of RCH programme. Similarly, many institutions have allocated thesis subject and completed 13 research projects and published 20 papers on RCH in the past two years. Faculty members (60%) have been involved in continuing education and teaching programmes of paramedicals at various levels. Similarly, the components of RCH programme have been incorporated into the curriculum of PGs and 30-50 hours time is devoted for self directed learning, lecture discussion and seminars besides allocation of subject of thesis; over 12 thesis have been completed. Integrated teaching and training in RCH has been adopted by a few Institutions, only four gave affirmative answers. Hopefully, RCH phase II further enriches teaching training programme.
The programme of orientation of faculty of Community Medicine of Medical Colleges was a challenge indeed, as also a pleasure for the Secretary General of IAPSM. Encouraged by excellent support provided by Deputy Commissioner RCH training, Tribal and Urban slums, GOI, the association drew up the detailed programme. The contents of the programme were discussed with core faculty members of IAPSM, drawn from SN Medical College, Agra, UCMS Delhi, MAMC, New Delhi, PGI Chandigarh, LHMC New Delhi, AIIMS New Delhi and Govt. Medical College Srinagar, through informal discussions. The view points and experiences of core faculty members proved to be a useful exercise which encouraged and helped to draw up a feasible and realistic programme of orientation training. Viewpoints of executive body of IAPSM to the extent of their accessibility were incorporated. In general there was widespread endorsement for this endeavour.
Overall objective was to orient the faculty of Medical Colleges (teachers; lecturer and above) on Reproductive and Child Health Programme (RCH).
Specific objectives were:
Before the orientation training commenced, the senior Professors/teachers of Community Medicine of different States of the country, who had the potentials and active members of the IAPSM, were identified. They were invited for first orientation training programme conducted at Rohtak. Concurrently the resource persons for RCH Training were identified and contacted in person by the Secretary General of IAPSM. The resource persons were briefed on the scope and objectives of the orientation-training programme. Learning resource material relevant to RCH Programme was procured from Mass Mailing Unit of MOHFW, Govt. of India as also from the Deputy Commissioner training GOI. Some of the learning resource material was duplicated at Rohtak by Photostating. Copies of the District rapid household surveys, National Family Health Surveys I and II as also Facility surveys were also procured. Part of these learning resource materials were given to participants as background material. State coordinator of RCH and Director General Health Services Haryana as also District Training Officers were involved as resource persons.
The programme contents of orientation training programme were adequate, meaningful and purposive as also specific and relevant to RCH Programme. The focus was on learning rather than teaching. Learner's interest was sustained throughout the course through participatory methodology adopted in the orientation programme. Sessions were deliberately designed in such a way that the presentation was made in 30-35 minutes and rest of the time in each session focussed on active discussion and seeking clarifications.
The sessions were interactive, participatory and problem centered. Learning was enriched by focussed presentation, followed by discussions. The material was presented through multimedia and OHP and photocopies were made available to the participants to the extent possible within the constraint of resources. The experiences of different places were pooled down to enrich the interaction and learning. Each orientation training programme was scheduled for two days and the slated activities started around 10 AM and concluded around 5.30 PM. Snacks and tea were provided in between the sessions at the site. At most places, the participants were residents and there was plenty of scope for interactive mutual discussions and drawing from each other's experiences.
Corresponding to each session the learning resource material was identified and was listed for further reference. The participants had the advantage of access to published articles related to RCH programme in the Indian Journal of Community Medicine, which is an official organ of the IAPSM. Further, sources of availability of learning resource material were indicated. To have a continuous learning and enrichment of teaching and training programmes, the participants were motivated to use live situations and data of monitoring reports and rapid surveys related to RCH programme. They were provided with convincing evidence as to how the teaching and training programmes of Biostatistics and Epidemiology could be enriched through adequate use of data bank of RCH programme available at the level of Subcentre, PHC and District, State and National level. Each topic/session had its sessional objectives and methodology to learn as also learning aids to be used. The reactions and views of the participants were obtained at the end of the orientation training programme and were fed back to resource persons and these have been documented in this report as well.
The resource persons used for RCH orientation training programme were eminent and experienced persons in the field of Reproductive and Child Health Programme. Deputy Commissioner Training (Tribal and Urban slums) Chief Director M&E (RCH), Assistant Commissioner for RCH Training, D.C. Child Health, WHO invitee and consultant from NIHFW, New Delhi could participate and interacted at Rohtak, Chandigarh, Delhi, Ahmedabad and Sewagram respectively.
During each orientation training programme, three hours were devoted for group work (two sessions). Whole batch of participants was divided into 2-3 small groups. Tasks given to groups comprised of:
It was the considered opinion of the groups that no extra time was needed to incorporate the specified RCH areas into the curriculum, within the allocated time frame of 385 hours (130 theory and 255 hours of practical) for the discipline of Community Medicine. Similarly sufficient time is available during postgraduate period.
|Sr. no.||Specific Thrust Areas||Mechanisms||Actions|
|1.||Paradigm Shift-RCH||Theory lecture||Discussion-Seminar Topics to Students|
|2.||Community Needs Assessment (CNA)||Family study on longitudinal basis Exit Interview of clients in clinic or OPD/indoor. Rapid Household survey in community Case studies or live data in community Mapping out of healthservices-Environment||
|3.||Decentralized Planning Suncentre-PHC-CHC-action plans||Study of Rows and columns of subcentre action plan, record/registers of a faculty s/c, anganwadi/health post in urban slum||
|4.||Coverage and Quality of RCH Services||Observation and interview/discussion, visit facility of a s/c, A/W health post||
|5.||Health information Syste under RCH||Reporting formats of RCH programme and various reports. Mother based/home based records, growth monitoring records. District rapid household survey report, Dist. helth facility survey data, NFHS-I and NFHS-II data, Census data, Dist stratification data for RCH services.||
|6.||Gender sensitization and increase male participation in health and family welfare||Experience in one's own family. Ascertain practices in the allotted families. Case studies.Data analysis of census/syurveys on sex-ratio, female literacy, health care utilization, female foeticide, male female orbidity and mortality||Narration by studentsPresentation of findings Group discussions and seminar|
|7.||Participatory and decentralzation of planning, training,control of services and resources||
||Enlist the health responsibilities undertaken by PRI and Nagarpalikas, interaction between providers and PRI, nagarpalikas and other sectors; Partnership with private sector|
|8.||Issues of adolescent Health||Meet male and female adolescents in school or out of school or in the allotted family.||
|10.||Comunication and counselling for behaviour change||
All the learned members expressed in unanimity that corresponding to the broad areas identified there should be enough of learning resource material (LRM) on that very subject. Right now the basic learning resource material on the RCH Programme, CNAA approach, National Population Policy 2000, Draft National Health Policy 2001 is not readily available to most of the teachers of Community Medicine. It was deliberated in length as to how to streamline the flow of LRM on regular and continuous basis to the teaching faculty. One mechanism was that Ministry of Health and Family Welfare to ensure mailing of material to all the Life Members of IAPSM or at least to the departments of Community Medicine to begin with. Second mechanism was to retrieve the material through internet and the another mechanism thought over was to publish the material through Indian Journal of Community Medicine.
It was felt that most of the teaching and training of RCH components to UG and PG has to be extramural i.e. away from classroom settings. How to achieve a shift from "Class Room" to "Community". Discussions and deliberations ultimately led to consensus that developing regular and sustained interaction with the district health care delivery system and RCH programme officers and other programme officers will ensure continuing education of the faculty of Community Medicine on National Health Programmes. Periodical involvement of RCH programme officers in teaching and training programmes of UG and PG could fulfill the desired objective. These mutual interactions could be one way to enhance the access to learning resource material. The other view point was that the available learning resource material such as rapid household surveys, facility survey and NFHS I and II data should be extensively used by the faculty of Community Medicine to strengthen the teaching and training programme in relation to RCH components as also to enrich the training programme of epidemiology, biostatistics and health management.
Teachers of Community Medicine expressed that they were ready to accept full responsibility of Rural and Urban field practice areas and its administrative control, provided that State Govt. was ready to do so. This would enhance the teaching, and training programmes of Community Medicine including RCH programme on long term basis. By doing so the Community Medicine deptt. and Medical College institutions will be interacting with health care delivery system on sustainable basis and both would be drawing mutual benefits from each other. The Medical Council of India should intervene objectively on these issues.
It was voiced that the capacity of the department of Community Medicine be built further, through regular orientation training programmes for teachers. Ministry of Health and Family Welfare and Medical Council of India could support such an activity on continuous basis. IAPSM would do its best to spearhead such an activity through its annual conferences or zonal conferences with the financial support of national bodies. The participants expressed their feelings and concern in the areas of inadequate or non availability of transport, audiovisual aids, computers etc. which are so vital to impart community based RCH training and to accomplish research persuits.
The deliberations of the group work focussed attention on developing integrated teaching in the medical institutions. The group members felt that many areas of RCH identified by them need to be taught through integrated effort, as one discipline was not enough to impart total training on that issue (Gender issues, RTI and STI, Adolescent Health etc.). The other issue discussed was as to who will take lead or provide leadership on the subject of integrated teaching, this could not be resolved in the discussions, however, it was considered essential that it could be functional leadership or rotational leadership based on the issues involved. Setting up of a reasonably well developed medical education technology cell in each Medical College coordinated by the discipline of Community Medicine could go a long way.
All the participants agreed to give a fair trial to the action plans developed by them, in their institutions within the limitations of resources. It was agreed upon that the action plans would be implemented in letter and spirits and the process would be documented in terms of methodologies adopted, innovations made, extent to which health care delivery system programme managers involved in teaching training programmes, learning resource material procured, tested for adoption and worth or utility of that material, research projects in the area of RCH persued/completed in the next 2-3 years. The IAPSM would ensure these through follow up activities.
The nodal agency for training on RCH i.e. NIHFW has developed learning resource material for continuing education of different categories of health functionaries. These modules were developed in isolation without involving the professional body like IAPSM, there are several and severe gaps in some areas, this needs to be tested and filled. In the first instance let these modules be made available to IAPSM members and Deptts. of Community Medicine and the feedback of
community medicine faculty be obtained for further improvement of this package of material. Probably no one else is going to give feed back on this material. The participant faculty members assured that they would persue operational research studies within their limited capacities on the different components of RCH programme. Some were very keen to get involved in multicentric research studies, others felt that independent review studies of RCH could be entrusted to faculty of IAPSM.
Conventionally and invariably all departments of Community Medicine in the country adhere to Family Study exercises to all undergraduates and PGs in urban slum areas and rural areas. The participants observed that lot of information is collected under Maternal and Child Health Services and some of the key services and components of RCH were missing altogether. It was suggested that Family Study Schedules be updated to incorporate all the components of RCH Programme and the exercises on family studies be persued in the light of proposed action plan with due emphasis on all the thrust areas. Seeing is believing, hence the students should be shown RCH components in operation in nearby accessible areas. Conventional text books of Community Medicine have not been updated, hence the chapters on adolescent health, CNAA and Decentralized planning and RCH Programme as such are missing or inadequately covered by the teachers and consequently the students do not learn RCH strategies.
In the opinion of the participants it was considered essential that head of the departments and all faculty members should identify the thrust areas for teaching and training programmes and with defined sessional objectives, methods to be used to acquire the defined learning objective, essential educational aids to be used to enhance learning as also mechanism of evaluation and outcome of learning sessions. These exercises should be planned well in advance in the form of data bank and these must be updated periodically. It was proposed that data bank on research topics to be persued by IAPSM/faculty of Community Medicine be built up. During the period of internship training programme learning of skills pivotal to RCH programme can be persued vigorously and aggressively within the framework of regulations of Medical Council of India. Interns should be given responsibilities for a defined community to learn all about RCH, its planning, implementation, coordination, monitoring-evalution, community participation and learning to prepare action plan themselves during the course of three months residential training programme. However, it was disturbing to note that all was not well with internship training programme. At most of the places it is not being persued as resident training programme and it ends up as a visit programme and no impressions or impact is made on interns. The system of entrance examination has ruined the programme as such. Medical Council of India should take serious note of this situation. Serious evaluation of internship training programme is called for.
Teaching and training programmes for postgraduates in the discipline of Community Medicine varied considerably from institution to institution for want of uniform guidelines of Medical Council of India (these are in the pipeline most probably). Under the circumstances each institution persues three years PG training programme with curriculum developed at the level of institution. There are variations in the contents and approaches for PG training. Nevertheless there is enough scope to incorporate RCH components. The group work exercises indicated that whatever has been recommended for UG is also true for PG, in addition the postgraduates in Community Medicine should strive to pick up and choose thrust areas and components of RCH as a subject of their thesis protocols, besides being actively involved in teaching programmes of undergraduates in the class room settings and field demonstration.
It was suggested that all the postgraduates should complete one project on RCH apart from thesis work. This should be in the form of a rapid assessment survey or case study or focus group discussion methods to build up data and information. Postgraduate students should endeavour to learn and work on advanced learning of epidemiology and biostatistics and management sciences based on the RCH data generated at various levels. All PGs should, infact, be able to prepare action plans, work schedule and develop managerial skills to work out the requirements of RCH services to meet the unmet needs. Other exclusive areas for PGs under RCH programme are planning and evaluation of RCH services, intersectoral coordination, community participation, health manpower development, continuing education, health information system, budgeting, partnership with private and NGOs and public health system, user charges, health reforms, development of quality parameters for RCH services, contents of initial training for multipurpose health workers, training needs assessment and evaluation of training programme, supervision, coordination and monitoring mechanism in RCH programme as also development of physical infrastructure.
Roh. = Rohtak; Ch.=Chandigarh; Luk.=Lucknow; Pat.=Patiala; Gw.=Gwalior; D=Delhi; Ag.=Agra; Ahm.=Ahmedabad; Jai.=Jaipur; Sewa.=Sewagram.
During the short period of mid July to mid November 2001, i.e. four months period, the IAPSM could organize 10 orientation programmes at different places in the country. An impressive coverage of 256 participants and local resource persons was achieved through this unique effort of IAPSM. The orientation training programme was adequately supported by the indulgence of 27 external resource persons drawn from different streams of participating States and national level eminent personalities. On an average, 23 participants were registered per course. Average number of resource persons per course was 4.8. Further, the number of participants ranged from 17 to 25 per course. Official rank and designation of the participants in various courses consisted of 70 Professors, 114 Associate Professors/Readers, 22 Lecturers, 10 other categories and 40 Postgraduates.
Thus the qualitative coverage was adequate as per norms of staffing per Medical College. It was observed that faculty position of teachers of Community Medicine in different Medical Colleges varied widely. There were Medical Colleges where only 1-2 faculty members were in position to spearhead the teaching and training programme in the discipline of Community Medicine. Poor physical infrastructure in terms of building, transport and paucity of urban/rural field practice areas were also voiced strongly by the participating faculty members. These variations in terms of staff and facilities within the State raises serious questions of distribution and deployment of faculties and policy thereof. In the State of Punjab, two Govt. run Medical Colleges had poor strength of teachers, similarly, in the State of UP and MP. The situation was pretty bad in some of the Medical Colleges. Poor resources in terms of availability of LRM and A.V. aids were also voiced strongly.
Besides the faculty of Community Medicine, the postgraduate students and other faculty members also derived the benefits of orientation training programme, which have not been reflected in the coverage or output. To a certain extent the organization of orientation training programme on RCH in different Medical Colleges of the country has empowered the local Medical Colleges to build their training capacity and confidence. Further support can definitely enhance their contribution in terms of coverage and quality of RCH programme on the ground level. Unit cost of training worked out to be Rs. 3250 per participant, which is quite meagre an amount. This can be further reduced with more decentralization and efficient management. This cost is worth when translated into benefits and impact.
The overall environment for the conduct of orientation training programme was quite conducive for learning. The participants rated these training programmes as useful continuing education programme and post-training test revealed enhancement of knowledge ranging from 70-95%. The areas liked most were CNAA, decentralization, Adolescent health and gender issue, besides operational research projects in RCH.
Hurdles/Inadequacies: Over 80% of the participants expressed that learning resource material on RCH was inadequate and not available readily. Essential material like CNAA, NPP 2001, RCH strategy and plan of action were not made available as they were not on the regular mailing list of the MOHFW or State Health Directorate.
Medical Colleges have not been involved in the process of in-service training programme on RCH being persued at the State Institute of Health and Family Welfare and district level or at Regional Institute of Health and Family Welfare. Similarly, in development of modules on continuing education programme, by the nodal agency on training in RCH (NIHFW) did not involve the faculty of Medical Colleges, thus a wonderful opportunity was missed indeed, to have the wisdom of teachers of Community Medicine. Another factor, which hindered the smooth conduct of training and its acceleration, was the inadequate interaction between the State health care delivery system and the medical institutions on regular and sustained basis. Since the implementation of RCH programme rests with district health authorities, the operational aspects of the programme and many newer strategies under RCH were difficult to comprehend in one go, unless sustained interaction is there for continuing education. The other impediment in the conduct of training programme was non existence of rural/urban field practice areas with respective Medical College. Medical Colleges in the State of Madhya Pradesh, UP, Punjab, Maharashtra and Delhi do not have rural field practice areas, leave alone the administrative control thereof. Most of the departments of Community Medicine are not fully developed in terms of adequate A.V. aids, computers and staffing positions as also transport including POL and drivers, which impedes the mobility and comes in the way of teaching training and research programmes.
Follow up mechanisms of activities undertaken: Over 80% of institutions have incorporated the RCH Programme and its strategies into the undergraduate programme and 16-20 hours are being devoted for Lecture discussion; demonstrations and observational visits in the areas of concept of Paradigm shift, Community needs assessment, Gender issues, Adolescent health, Decentralization, Subcentre and PHC action plans and client satisfaction and quality of care, RTI/STI and communication strategies under RCH. During final evaluation, theory papers cover atleast one long question and short note and viva voca and practical exam also covers adequate elements of RCH programme. Similarly, many institutions have allocated thesis subject and completed 13 research projects and published 20 papers on RCH in the past two years. Faculty members (60%) have been involved in continuing education and teaching programmes of paramedicals at various levels. Similarly, the components of RCH programme have been incorporated into the curriculum of PGs and 30-50 hours time is devoted for self directed learning, lecture discussion and seminars besides allocation of subject of thesis; over 12 thesis have been completed. Integrated teaching and training in RCH has been adopted by a few Institutions, only four gave affirmative answers. Hopefully RCH phase II further enriches teaching training programme.
Based on the interactions with faculty of 52 Medica Colleges in the country the following suggestions/recommendations are offered for further actions:
1. Since the faculty of Community Medicine department plays useful role in teaching, training and research activities of RCH programme, hence the learning resource material in respect of RCH programme and other national health programmes should be mailed to them regularly. They should be kept on mailing list. Full addresses of all faculty members have been handed over to the DC Training (RCH Tribal and Urban Slums) as also to Chief Director M&E, Nirman Bhavan, New Delhi.
2. Faculty of Community Medicine is readymade research pool of committed field workers best suited for operational research persuits. Therefore, their research capabilities be fully utilized in RCH Evaluation Programme in the following areas:
These are some of the urgent issues, which can be explored through operational research programme by the IAPSM.
3. Medical Colleges should have administrative control of three rural field practice areas as also urban field practice areas for effective teaching, training and research persuits in RCH and other national health programmes. The IAPSM should evolve effective models of Primary Health Care and RCH programme for urban slums, adolescent health and coverage of tribal areas and services for elderly people.
4. Sustained interaction between health care delivery system and faculty of Medical Colleges is essential for enrichment of medical education as also to improve the training and health care delivery system. Faculty of Medical Colleges and IAPSM should be invited by State Health Authorities/National Health Authorities (MOH&FW), GOI for better interaction. It should be institutionalized with fixed periodicity. Adequate share of training grant and research funds, vehicles, POL and learning resource material be provided by respective State to its Medical Colleges. Department of Community Medicine must be strengthened in terms of mobilitytransport and AV aids including computers.
5. IAPSM should be involved to assess the utility of various modules produced by nodal agency for various categories of functionaries of RCH programme. This would necessitate updating and modifications based on the field observations, for which the competency rests with members of IAPSM and faculty of Community Medicine.
6. Inter-sectoral coordination between different sectors, partnership of private sector with public sector and role of NGOs and functioning of PVO/NGO models, their worth and effectiveness to meet the unmet needs of reproductive health of varied groups should be explored by associating IAPSM (professional body).
7. Since the RCH II is on its anvil, the programme of involving IAPSM on the areas specified above should be considered right now. Trained manpower of IAPSM could undertake training activities as also updating the training modules apart from operational research.
8. The Medical Council of India as a regulatory body for medical education should act on the action plan which is based on field observation, gathered by IAPSM from the experiences of faculty of 52 medical colleges in the country. The curriculum proposed by IAPSM for UGs and PGs should be incorporated/adopted into the programme of training of UGs and PGs in due course of time and its implementation by all medical colleges in the country. The MCI owes its responsibility to enrich medical education and improve its quality through regular feed back, it can bank upon professional association like IAPSM and this document should be used as rich feed back.
9. Syllabi and curriculum of Nursing professional, Multipurpose health workers male and female should have incorporation of RCH programme components and recent developments. Training of trainers be persued vigorously in order to produce a right kind of product through its training institution. IAPSM can help the Nursing Council on this issue.
10. Training of rest of the faculty of Community Medicine needs to be persued urgently. Support grant for such an activity be provided by GOI and WHO to accomplish the remaining task in rest of the States which have not been covered.
11. Continuing education for team training involving Deptt. of Community Medicine, Paediatrics and Obst. and Gynae. be undertaken at the level of Medical Colleges to promote integrated teaching in RCH Programme.
Incorporation of RCH into curriculum of UGs and PGs would depend much on the mindset and attitudes of heads of the departments of Community Medicine, who owe their responsibility towards education and training. IAPSM would continue its efforts to inspire the faculty of Community Medicine. Whatever has been proposed in this action plan is to be viewed as a small beginning and not the endpoint in itself.
Lal S etal
Orientation of faculty of Community Medicine in RCH