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Indian Journal of Community Medicine

Dhanwantri Oration: Accreditation of Public Health Courses in India - The Challenge Ahead

Author(s): B. S. Garg

Vol. 29, No. 2 (2004-04 - 2004-06)

*Professor and Head Department of Community Medicine, MGIMS, Sewagram, Wardha.

Introduction

It is said that 80 years ago William Osler, the great physician and educator told an undergraduate medical class "he had good and bad news for them. The good news was that half of what they had been taught would be out of date in 10 years. The bad news was that no one knew which half". In India we have witnessed significant changes in public health in recent years. The economic liberalization and market economy has resulted in both good and bad effect in the health field. In the developing world the diseases of affluence are being superimposed upon the diseases of poverty. New public health challenges have emerged in the form of demographic and epidemiological transition and environmental degradation; emerging infectious diseases and anti-microbial resistance.

The onward march of technology presents glowing prospects. The human genome project has incalculable potentials in the prevention of crippling diseases and surgery is being transformed by the use of imaging techniques and lasers. Nevertheless, the list of development and opportunities is infinite while resources both economic and human are finite. The continuous increasing demand outstrips supply and rationing inevitably follows, as resources allocation becomes stricter. Consistent and sustained leadership and political support is needed to promote and strengthen the public health system through strategic initiatives, and effectively communicate its value, relevance and importance. The public health infrastructure requires strengthening, and there is a need for improvement in training programmes for public health courses. As the 48th World health Assembly recognized in 1995 both medical practice and education need to be reoriented to achieve relevance, equity, cost-effectiveness and quality in this changing scenario, the same is more relevant for public health. To keep pace the public health speciality has to take the challenge of overall development of community where it plays a central and integral role in the development process.

The status of Public Health discipline in India is not satisfactory. It has not been able to attract attention of politicians, bureaucrats and other policy makers. The discipline also doesn't enjoy a respectful position amongst medical fraternity. The situation of the department of community medicine in medical colleges and state and district training centres as well as National Institutes is quite bad and they have miserably failed to deliver the desired effect. The main challenge for public health institutions in India is to reflect social responsiveness/social accountability, developing quality assurance system, keeping pace with advancing technology and developing an interface with the community and health care delivery system. Since there is no formal and effective accreditation system in the country at present, therefore any formal accreditation system specially directed towards public Health teaching in India should address these concerns.

Advocating the relevance of standards for social responsiveness does not mean that features of public health at medical schools and medical education should be made uniform but the main concern is to respond as efficiently as possible to local health needs for optimal utilization of local health resources. The health care; medical practice and medical education should work in partnership to serve the community based on values of quality, equity, relevance and cost effectiveness. A framework for accreditation would therefore encompass elements related to the impact of public health schools and medical education on career choices of graduates, on the work of medical profession and on the performance of the health system. It should also consider the capacity of public health schools to demonstrate productive and sustainable partnerships with other important stakeholders of public health for improving the delivery of health services as well as people's health status. In the area of public health practice and education in South-East Asia, a regional consultation of experts from a variety of disciplines interested in population-based medicine was held at Calcutta from 22 to 24 November 1999. Participants at this meeting considered the scope of public health to include poverty alleviation, equity, quality, social justice, environmental protection, community development and globalization. The leadership role of public health, creation of career structures and reforms in public health education, training and research are some of the key elements of the "Calcutta Declaration".

The optimal Educational approach in medical education should focus in a manner where the young graduates can take up the roles and responsibilities expected from them in order to face efficiently the challenges in the health sector. WHO, over the years, has promoted the integration of health services and health manpower development. The global conference on international collaboration on medical education and practices, sponsored by WHO, at University of Illinois College of Medicine, at Rockford, Illinois, USA in 1994 urges that, "the priority concern be focused on the interface of health care, medical practice and health professional education so that there is ready and coordinated responsiveness to societal needs. This interface serves as a foundation for a partnership between university, government, health care providers and community that serves as the focal point for their interactive strengthening of their respective areas of responsibility and interest". Further it was recommended "that the direction of action should be towards community based, policy relevant, publicly accountable system of health care and educational development that results in equitable, effective and compassionate care for patients, families and communities in keeping with the needs and values of each society".

In the last few years there has been a mushrooming of medical schools in India without adequate need assessment and feasibility studies. These schools enjoy political and corporate patronage. Accreditation of educational institutions is seen as a means for improving the quality of educational programmes. Due attention should be given to quality assurance in training programmes and pre-service education. Professional associations and MCI should respond to WHO-initiated programmes on development of accreditation guidelines. The quality assurance in turn will help the medical schools to improve their social responsiveness in meeting people's health needs. Accreditation of educational institutions and programmes is a relatively new concept in South-East Asia. The dictionary meaning of this term implies official recognition, general acceptance and assurance of quality. The purpose of accreditation in our context is aimed at developing a system to determine and certify the achievement and maintenance of minimum standards of education in the different occupations and professions in the health system. The United States has perhaps the most well established system of checks and balances in public health education in the graduate programme. The Council of Education for Public Health is an independent agency, recognized by the US Department of Education to assist in accreditation of schools of public health, and public health programmes. In Australia and New Zealand, the relevant professional council is responsible for accreditation. In the United Kingdom, the General Medical Council is the body responsible for recognition of medical won. The primary responsibility of the accreditation body is to attest to the educational quality of programme, directly serving the interests of t e public and of the students enrolled. An educational institution in public health is responsible for selection and education of students culminating in certification of competence to practice public health. To do t the school should provide resources, including faculty and adequate facilities to support the curriculum offered. The public health institutions should have a clearly formulated and publicly stated mission statement with broad objectives for each course. The curriculum must be designed to install in its learners the knowledge and skills fundamental to the practice of public health. In addition, there is a need to instill habits of self-directed life-long learning, dedication to the service of communities, and values and attitudes consistent with the compassionate profession. It is also important that the methods of assessments match the objectives of public health education.

The process of accreditation usually entails an institutional self-assessment, preparation of database, cataloguing of the programme and site visits by member of the accreditating body. Generally, this process is repeated at periodic intervals as decided by the accrediting agency concerned. To be accredited, the programme must meet the national standards for accreditation through a process of study and debate, including discussions with the public, students, faculties and practitioners.

Su Delong had this to say at the eight Regional Meeting of Directors of Representatives of School of Public Health in Bangkok in 1979: "We ought to devote limited resources in the most judicious way possible to the training of the most appropriate type and number of health personnel to best serve the needs of the population".

"The time of the classical type of schools of public health and schools of medicine as well seems to be over and new alternatives are coming up concerning the internal structure of public health programmes and medical training programmes as well" (Ref. Healing the Schism, Kerr L. White page xii). Public Health training is not based on the needs of the community. In many South East Asian countries including India, the curriculum for public health education was designed several decades ago and very few changes have been made since then. There is a need to urgently address these issues as high lighted in the Calcutta declaration on Public Health. It is necessary to identify the needs, the teaching methods, assessment and place of training.

Public Health needs: The public health needs of regions vary from country to country. It also varies from one part of the country to the other especially in countries as large as India. The needs differ in urban and rural; highlands, mid lands and low lands; desert and tropical forests; economically well to do and the marginalized. Hence the needs are to be locally assessed. There cannot be a common course content. The first step is to assess the needs. Needs can be identified through an inquiry driven strategy or using existing data such as mortality, morbidity and also by involving the community using the participatory process. One also needs to be aware that the needs are changing rapidly. (The Table I highlight these needs.)

In India we face the triple burden of infectious diseases which have not been controlled, those which were controlled and are re-emerging such as malaria and plague, and the non-infectious diseases such as diabetes, hypertension, cancer which increases with age and the problems of limited resources. Disaster management both natural and man-made is another priority area. The World Health Report of 1995 had identified the following issues as priority problems: "The ancient scourge of leprosy still causes 600,000 new cases a year. Between 2 and 3 million people are disabled by the disease".

Table I : Income range with life expectancy at birth and infant mortality rate

Income range (per capita GNP in US $ 1992 Life expectancy at birth (Years) 1993 Infant mortality rate 1993
15,000 and above 70-79 5-26
10,000-14,999 72-78 7-22
5,000-9,999 63-77 9-68
1000-4,999 51-76 10-93
500-999 45-72 24-133
100-499 43-71 27-158

(Ref: World Health Report 1995-Bridging the Gap)

WHO estimates that one-quarter of the World's population is subject to chronic intestinal parasitic infections which have insidious effects on growth, nutrition and cognitive function in children, and on the development of girls and women". "By the year 2000, the cumulative total of HIV infections worldwide could reach 30-40 million". "The outbreak of plague in India in 1994 was a stern reminder to the world that a dreaded disease often regarded as a scourge of the past still exists". "Diabetes mellitus is a growing public health problem. More than 100 million people will suffer from diabetes by the end of this century". "On an average smoking kills 6 people a minute. Smoking is already killing 3 million people a year worldwide". "There are an estimated 330,000 occupational injuries everyday in addition to a daily toll of about 600 deaths". "Dementia, a sad and often lengthy life in limbo for both sufferers and their relatives, is believed to affect at least 22 million people world wide". "In many countries the skill mix of health teams is still inappropriate, and personnel are poorly distributed. Market forces alone cannot achieve a rational and cost-effective mix". "Half of world's population still lacks regular access to the most needed essential drugs". "There is a need to shift emphasis from preventing death to preventing ill-health and enhancing the quality of life". The needs will also differ at different levels of the health care system - the Village Health Post or Sub-Centre, Primary Health Centre, District or State Headquarter. This consultation should look at the Community level, PHC level and District level. Based on the needs it is necessary to identify the skills required. If possible generic skills should be listed at each level. The knowledge skills and attitude required to carry out these tasks will then have to be listed.

Teaching learning methods: The word learning rather than teaching is used deliberately because learning implies an active process and prepares the person for life long education. It is also a more participatory process whereas teaching implies the transfer of information from the teacher to student.

Today most of the education in public health is carried out within the four walls of the ivory tower of an institution with limited exposure to the community using didactic lectures. Didactic lectures have been defined as "transfer of information from the notes of the teacher to book of the students without going through the minds of either person". Education has to be an active process so that it is student centred, inquiry driven and evidence based and problem solving. The role of the teacher is to enable the student to learn and guide the thinking process.

This consultation also needs to identify the core-curriculum. "Core" is the centre of an apple, which is thrown away after eating the flesh around it. But the "core" contains the seeds and is responsible for its dissemination and multiplication. The flesh of the apple was only to attract person to help in the process of dissemination. So also the curriculum must have a core" which is the centre, which is the most essential without which the rest of education is of limited use.

So the accreditation in Public Health requires the following: Courses and Training programmes offered by Public Health schools for paramedical personnel offering short term courses and regular programme for training of health workers (male and female), public health nurses, sanitary inspector and Health educators etc. - Medical and Nursing Schools offering undergraduate and postgraduate courses as per recommendations of MCI and Nursing Council of India. National, State and District Health and Family Welfare Training Centres providing in service training. CME programmes by professional bodies and National Academy of Medical Sciences.

Suggested Criteria for Accreditation: Based on the recommendations of the World Federation for Medical Education, the following were suggested in a WHO consultation at Chennai in Jan-Feb 2002 and they may further be considered in a small group in order to develop an effective and acceptable implementation strategy

The institution must define its mission and objectives and make them known to its constituency. The mission statements and objectives must describe an educational process to produce a public health professional competent at various levels with an appropriate foundation for further training in public health, in keeping with the roles of the professionals in the health system.

The institution must define what competencies its students should exhibit on graduation, including the relationship of such competencies to the diverse needs of society.

Curriculum models and instructional methods. The institution must define the curriculum models and instructional methods employed (discipline, system, skill based etc.) on the basis of sound learning principles.

Role of Behavioural and Social Sciences and Medical Ethics: The institution must identify and incorporate in the curriculum the contributions of the behavioural sciences, the social sciences and medical ethics that provide the knowledge, concepts, methods, skills and attitudes necessary for effective communication and decision making and implementation of public health programmes.

Role of Skills: The institution must ensure that students acquire knowledge of public health management sciences and skills (including communication skills) necessary to assume management responsibility upon graduation. Skills should be given higher priority than knowledge.

Curriculum Structure, Composition and Duration: The institution must describe the content, extent and sequencing of courses and other curriculum elements, including the balance between the core and optional content.

Assessment Methodology: The institution must define and describe the methods used for assessment of their students, i.e. the balance between formative and summative assessment methods, the number of examinations and other tests, the balance between written and oral examinations, the use of special types of examinations.

Recruitment and Admission Policy: The institution must have a recruitment and admission policy document.

Physical Facilities: The institution must ensure that it has sufficient educational resources for the student population and for the delivery of the curriculum, including libraries, lecture halls, tutorial rooms, laboratories, computers and field practice areas etc.

Pedagogy Expertise: The institution must have a policy on teaching and learning methodology and the use of educational expertise.

Exchange with other Educational Institutions: The institution must establish a mechanism for programme evaluation, and ensure that basic data about the public health programme is available through monitoring of the curriculum and of student progress, and ensure that programme evaluation addresses identified concerns.

Student Performance: Student performance (average study duration, scores, pass and failure rates, success and dropout rates) must be analysed in relation to the curriculum.

Organisational Structure: At the outset a group of faculty members must form a curriculum committee, which should be given the authority to design and manage the curriculum.

Interaction with Health Sector: The institution must have a constructive interaction with the health and health-related sectors of society, government and reported NGOs.

Continuous renewal of the Medical School: The institution must as a dynamic institution initiate a programme and procedures for regular reviewing and updating of fundamentals of the institution, its structure and activities.

Accreditation process should be able to assess the performance of a health care organization and be based on an evaluation of its compliance with evidence-based and .consensus based standards. These standards address patient care (i.e. their assessment, their treatment and the protection of their rights) as well as organizational processes such as the management of human resources, information and quality: Notably, the accreditation process can be designed to accommodate specific legal, religious and cultural factors within a country.

Challenges in Accreditation: Looking ahead, the profession and the health care organizations have several challenges with respect to accreditation. First, we need to make the accreditation process relevant while delivering value to the institution. That is, we must demonstrate that the processes of pre-survey preparation, self-assessment and on-site evaluation can result in more positive health care outcomes. The question remains: When institutions and/or health care professionals are evaluated through an accreditation process, does it make a difference in how care is delivered?

Learning environment: Learning environment plays an important role in education. The present education is confined to classroom or demonstrations or laboratory works where as the actual problem they face in public health are in the community. Classroom practicals rarely reflect the true situation. Primary Health Care of Public Health cannot be taught in vacuum. It has to be hands on experience in the community or in any part of the health care systems. Skills such as community diagnosis, prioritization, planning, supervision, monitoring, management of data, investigation of epidemic, and problem solving, communication-with community and problem solving are poorly acquired through classroom teaching. In 1979 Professor C. C. Chen of West China University visited a series of North American medical schools of public health. He had this comment to make

"Those I was familiar with in the United States, seemed to be concerned more with theoretical knowledge and scientific research than with the practical application of knowledge for the benefit of the general population. Regrettably, decades later public health professors in the West seemed to be encouraging graduate students along the same lines".

And of a visit to his alma mater, he wrote:

"At Harvard University, I visited the Schools of Public Health and Medicine. The faculty had increased enormously, and its interests seemed to revolve less around challenging the students than in generating papers on subjects of high academic interest. Many research topics, as far as I could see, had no connection with major health problems".

One needs to ensure that we do not fall into the same pitfalls.

'What then, is the ideal community for such training? The "community" be a come, village, school, a factory or any part of the health care such as PHC, District hospital or anything other than the training instruction / public health laboratory. This would differ for different situat ions and levels of expertise. There is a need to identify these centres and aIso ensure that these centres are suitable for the learning process. The challenge in public health training is to provide a suitable environment for learning. If Community Based Education is an important method to be adopted for training in public health, it is essential that all training institutions be linked to a health care system. The ideal situation is for the training institutions to have its own field practice area with the staff similar to that of the national health system so that the trainees get hands on experience and develop these essential skills. If this is not possible, institutions of public health should be closely linked to government health care system where the training institution is given an opportunity to use a defined geographical area with all its staff for the training purpose.

The geographic area and population will differ from place to place. It may be as small as one PHC (approximately 30,000) or as large as one District (one million population). The lack of such faculties has contributed to the decline of public health training globally. If the public health training institutions do not have the facilities they could work in collaboration with NGOs who have such programmes. The curriculum has to be reviewed periodically at least once in five years because the needs change and the facilities and technology also change. Education is a dynamic process. The challenge of public health training is to identify these lacunae and build on our services, produce health professionals with the skills required to identify priority health, be able to provide the required services or identify persons who can help to reduce the problem. Another important challenge is to establish that accreditation satisfies the need for public accountability. This means the process must be cost-effective and successful in eliminating medical errors- a real and serious problem worldwide. The following issues needed to be addressed for meeting the challenges

Appropriate training of professionals in Public Health: Public Health training in India started with Diploma courses in Public Health (DPH), which focused on sanitation, environment and vector control. There should be more emphasis on priority areas and professional needs of the modern Public Health practitioner, such as health management, health economics, epidemiology, behavioural science, environmental science and primary health care. The MD (Community Medicine) programme of 3 years' duration, started in the 60s, had, for the most part, been training physicians to become teachers. Many Public Health institutions functioned in isolation without any clinical or health service responsibility. The decision of the Ministry of Health that each medical college should take responsibility for providing health services at least in three PHCs had not been implemented.

The National Institutes like AIIPH, NIHFW, NICD, NIE and others had not developed to the extent anticipated. Though National Committees had periodically stressed the need for establishing Institutes of Public Health, very little had been done about it. This needs to be addressed urgently.

IAPSM should lead a consortium of Public Health training institutions providing health services either independently Or in collaboration with the government, and carrying out essential health research or health systems research. Five or six institutions could carry out the common core­ curriculum, with each institution specializing in two or three areas, such as, epidemiology, behavioural science, health occupational health, health education, and health economics. Training should be student-centred, problem-oriented, integrated, community-based, need-oriented and with electives. Latest learning technologies should be utilized. A national body should recognize and monitor the programmes. Periodical accreditation would ensure uniform standards of training and evaluation.

Job Opportunities for Public Health specialists: Public Health had not been attracting the best candidates from the health profession. Public Health specialists had very little opportunity to do private practice or function independently. Those entering government service often got frustrated with the system. Public Health Specialists rarely become Directors of Health Services. Selection for the DGHS' post being restricted to the Central Health Services officers, outstanding Public Health personnel from states had not been able to lead at the national level.

Improving Health Information Systems: Though the Centre and States had established Health Information Systems (HIS), they functioned very slowly and inadequately making it difficult to act on the generated information for preventing epidemics, evaluating programmes or making policies. A few States had started modifying/re-organising the HIS to make it simple and easy, facilitate quick retrieval, prompt analysis and timely dissemination to the programme managers.

Integration between Curative services and Public Health: Clinicians and Public Health professionals had very little interaction. Public Health Institutions needed to think globally and act locally. The Community Medicine department of medical colleges should be more involved in Public Health services. Government, community and academia should work together.

Recommendations for IAPSM: Establish a mechanism for reviving current status of all Public Health training institutes using evidence-based criteria in relation to numbers, distribution, skillmix, career advancement opportunities etc.; Establish a focal point/steering committee to oversee further development of existing programmes for education and training of Public Health personnel, based on the guidelines agreed at the consultation and, develop guidelines to develop National Standards for accreditation.

Ensure adequate representation and participation of appropriate PH personnel in strategic national health planning and policy making. Strengthen managerial capacity and leadership capabilities of PH personnel; Develop partnerships with other government sectors, NGO'S, private organizations, and the community in developing PH services and training institutions.

For the G0I/MCI/WHO: Develop or strengthen existing regulatory bodies for accreditation of all institutions contributing to education and training of PH personnel Support the development and utilization of an accreditation system for public health institutions based on internationally endorsed criteria enabling equivalence between member states; Facilitate the establishment of regional networking of Public Health institutions for capacity building and research on issues of Public Health importance; Support regional exchange programmes for faculty and students to facilitate learning from "best examples" in PH education and training, and practice.

References

  1. Boelen Charles (2000) Challenges and Opportunity for Partnership in Health Development-a working group report. WHO, Geneva, 43-44
  2. Boelen Charles (2001) Accreditation and development of medical schools A global project, Towards Unity for Health, 4,6
  3. Jacott WE (2000) Accrediting the capacity to meet society health care needs - challenges to institutes and professions Towards Unity for Health 2, 22
  4. Jayawickramrajah The Way forward for health workforce in South-East PT (2201) Asia, Towards Unity for Health, 4,19
  5. Joseph Abraham (2000) Report of the regional consultation on development of Accreditation Guidelines for Educational Training Institutions and Programme in Public Health, Chennai, 31 Jan-2 Feb 2002
  6. WHO (2000) Public Health in South East Asia in the 21st Century WHO regional office for SE Asia, 37-42

Accreditation of Public Health

Dhanwantri Oration: 31st National IAPSM Conference, from 27-29 Feb., 2004 at PGIMER Chandigarh.

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