PUBLIC HEALTH EDUCATION
Year : 2010 | Volume
: 54 | Issue : 4 | Page : 184--189
How can departments of community medicine shape the future of Public Health Education in India?
Himanshu Negandhi1, Kavya Sharma2, Sanjay P Zodpey3,
1 Senior Lecturer, Indian Institute of Public Health, Delhi, India
2 Manager, Academic Programs and Adjunct Lecturer, Public Health Foundation of India, New Delhi, India
3 Director, Public Health Education, Public Health Foundation of India, New Delhi, India
Sanjay P Zodpey
Director, Public Health Education, Public Health Foundation of India, New Delhi
In order to effectively respond to a changing public health paradigm, it is imperative that the medical education and overall public health education (PHE) parallel the public health challenges faced by countries. Community medicine departments play a crucial role in PHE. This review analyzes the current situation of community medicine departments in the context of PHE, using a framework that outlines academic activities undertaken by these departments. This framework includes the syllabus of academic programs, internship, and infrastructure and faculty strength in the community medicine departments. The review also discusses how skill building of existing faculty members can help us in addressing emerging public health issues, and the role of partnerships and collaborative activities in advancing the PHE agenda, thereby continuing to shape the role played by these departments toward shaping the future of PHE in India.
|How to cite this article:|
Negandhi H, Sharma K, Zodpey SP. How can departments of community medicine shape the future of Public Health Education in India?.Indian J Public Health 2010;54:184-189
|How to cite this URL:|
Negandhi H, Sharma K, Zodpey SP. How can departments of community medicine shape the future of Public Health Education in India?. Indian J Public Health [serial online] 2010 [cited 2020 Aug 15 ];54:184-189
Available from: http://www.ijph.in/text.asp?2010/54/4/184/77257
A responsive and effective public health delivery system is a vital investment. Health gains can also translate into financial gains. Health priorities change with times, reflecting a social, economic, and global health imperative. In order to effectively respond to this changing paradigm, it is imperative that the medical education and overall public health education (PHE) parallel the public health challenges faced by countries. PHE is the strut supporting the health systems. Traditionally, community medicine departments have played a central role in PHE by offering training to medical graduates in India. Through this review we will try to examine the potential role that can be played by community medicine departments in shaping the future of PHE in India.
The evolution of medical education and PHE-A historical background
The evolution of public health in colonial India has been chronicled earlier,  with the formation of the Indian Medical Services in 1896 and the subsequent transfer of public health, sanitation, and vital statistics to the provinces in 1919. The Calcutta Medical College was established by an order in 1835 to fulfill the growing need for health professionals.  The establishment of The All India Institute of Hygiene and Public Health (AIIH and PH) - Kolkata in December 1932 making it the oldest school of public health in south-east Asia  was a welcome development toward imparting PHE in India. Public health and medicine have been mutually dependent and interact with each other, in the past as well as in modern times.  Such an interaction can be seen in the history of development of the discipline in India as well where there was a healthy admixture of clinical and public health responsibilities.
The PHE drive, which developed in Europe with a thrust on the influence of social policy and related aspects upon health,  was the impetus for the development of the principles of social medicine. This drive emphasized a predominant role of social factors in shaping the population health. While hygiene and prevention came to the forefront following an understanding of the biological causes of diseases,  public health medicine was the result of integrating health services with community medicine in the United Kingdom.  The traditional approach to PHE in India is through undergraduate and postgraduate training in medical colleges. The PHE system was expected to ingrain the basic tenets of public health in the ethos of medical students. The aim was to embed a problem solving and community outlook at both the undergraduate and the postgraduate level.
The Health Survey and Development (Bhore) Committee Report of 1946 laid the foundation for community service by advocating for the institution of 3 month training in preventive and social medicine for physicians as part of the medical education system. The recommendations of the committee set the tone for integrating curative and preventive components of health care.  The Mudaliar Committee  further sought to strengthen PHE in the country by recommending schools of public health in every state to train medical officers, public health nurses, maternity and child welfare workers, public health engineers and sanitarians, dieticians, epidemiologists, nutrition workers, malariologists, and field workers.  The Shrivastava Committee Report  in 1975 set the tone by identifying the basic issues afflicting medical education. Among its observations, the committee noted that medical practitioners must change their outlook from an excessive concern with disease towards full social responsibility. While the committee noted that the establishment of the Preventive and Social Medicine Departments was a step in the right direction, it lamented that field areas were not adequately prepared and students devoted the largest chunk of their education in teaching hospitals (rather than the community) were responsible for aloofness of medicine from the basic health needs of the people. The Re-orientation of Medical Education (ROME) program of the World Health Organization for Asian countries was launched in 1977 and it was aimed at developing medical education system responsiveness and relevance to the needs of a country by making necessary curriculum changes.  The ROME scheme was planned to impart community-oriented training to medical undergraduates in primary health care.  The Bajaj Committee  suggested a central education commission for health sciences whose objective would include to implement desired changes in the contents and training programs of health and allied health personnel. The objective of the commission would also include implementing changes in the educational system that would facilitate essential linkages between health personnel and strengthen pedagogic skills with in-built review mechanisms. The recommendations of various committee reports re-emphasized the important role of community-based PHE, and its integration with the social obligations of the profession. The community medicine departments have played a central role in ensuring a "community outlook" to healthcare services, in contrast to the hospital-based clinical outlook of other specialties.
Recently, schools of public health have been launched in some medical and non-medical institutes, which can potentially complement the activities of the community medicine departments. These schools have expanded in number and offer opportunities for PHE to both medical and non-medical graduates. Masters programs in public health are offered currently by about 21 institutes, with some variation in the curriculum and specialization through elective units of study. Masters programs focusing on social epidemiology are offered by the Tata Institute of Social Sciences, Mumbai, while a Master of Public Health - Health Services Management is offered at the National Institute of Epidemiology, Chennai. In addition to these masters programs, while there is a growing recognition of the need for courses in specific areas of public health like occupational health,  the field of health management has witnessed the arrival of several institutes imparting the training programmes. 
Postgraduate courses in community medicine/preventive and social medicine
The objectives and goals of Postgraduate medical education in Community Medicine are to produce competent specialists to manage the teaching departments in the Medical colleges, or to manage health services and national health programs at various levels or to conduct biomedical research in the discipline of community medicine.  It is important to note that this objective for postgraduate education intends to equip students with skills in the three vital areas: adopting the role of a teacher, health manager, and researcher. Each of the 314 medical colleges in India has a functional department of Community Medicine/Preventive and Social Medicine with 141 institutions offering postgraduate courses in Social and Preventive Medicine/Community Medicine.  The annual output of postgraduates from these 141 institutes is only about 480. In addition to the postgraduate degree, 36 medical colleges also offer a Diploma in Public Health with an annual intake of about 136 doctors and 6 colleges offer a Diploma in Community Medicine with an intake capacity of 13 candidates.  This number is insufficient to meet the requirements at the country level for teaching, managing health, and research. The numerical inadequacy is compounded by a wide variation in the quality of teaching and syllabus.
Syllabus and internship
The synergy between clinical medicine and the overarching common objective of providing comprehensive health care has been enshrined in the current undergraduate medical education, with an objective to train physicians capable of delivering primary care within the primary health care approach.  Our MBBS curriculum is a legacy of the old British pattern and is overcrowded and outdated  with vague and unstated methods of acquiring the desired competencies. Therefore, the challenge is to work out a written protocol stating the competencies to be acquired and methods to be adopted to acquire such competencies within a time frame.  A substantial restructuring of the curriculum, with an increased focus on key competencies in several domains of public health is the order of the day.  The recent efforts of the SEARO office of WHO to outline the undergraduate curriculum is a step in this direction.  The recommended syllabus has been designed to ensure that the medical graduate acquires broad public health competencies needed to solve health problems of the community with emphasis on health promotion, disease prevention, cost-effective interventions, and follow-up.  The postgraduate curriculum can be expected to build upon the skills and application of the theoretical knowledge onto the community scene.
PHE by these departments was not just restricted to undergraduate and postgraduate teachings, but included an internship component that provided an opportunity to transfer clinical skills into communities. Although this is a compulsory component before obtaining a final registration of the degree, there is a growing realization that the internship program needs urgent attention. Mere completion of the requisite number of months of internship does not equate into inculcation of community health skills. Anecdotal reports suggest that interns give more importance to preparation of entrance examinations for postgraduate programs rather than the process of skill acquisition during internship. This places the community medicine departments' objectives at odds with those of the interns who would tend to look upon the posting as a chore and a hindrance to their preparation for these entrance examinations.
There is also an increased sense of urgency in contextualizing the medical education to the National Rural Health Mission (NRHM). The Task Force on Medical Education for the National Rural Health Mission  has recommended reformative and remedial action in medical education and health manpower development in order to meet the goals of the NRHM. This contextualization needs to be effected at all three levels highlighted earlier, the undergraduation level, the period of internship, and the postgraduate teaching. In addition to meeting the NRHM goals, the syllabus needs to encompass healthcare ethics, equity, gender issues, leadership skills, and group dynamics.
In addition to the conventional infrastructure like library, public health museum, and public health laboratory, the departments now need to invest in digitized library and computer laboratory as a complement to the prescribed infrastructure in community medicine departments. Digitized libraries can provide access to literature as it is predominantly in open access and can be easily accessed online. Computer laboratories will provide the students with an opportunity to use statistical software for their research work and must be equipped with all the basic software necessary for routine use.
Teaching in community medicine is different from the teaching offered in clinical departments
While the focus in clinical medicine is on an individual patient, community medicine recognizes that several additional determinants have also contributed toward the development of the same condition. Integrating these various dimensions cannot be a demonstration exercise in skills. Therefore, it is paramount that the teachers are equipped to train students using a variety of pedagogic skills, communication methods with hands-on teaching. A gradual creation of a PHE system for medical and non-medical streams, offering a basket of shorter certificate courses up to postgraduate courses has been suggested to address a higher demand for public health professionals in health systems across all levels.  The advent of medical and non-medical streams would impose newer challenges upon teachers who would have to train students with different backgrounds, exposure, and understanding of public health.
Recognizing need for multidisciplinarity in PHE
Public health is multi-disciplinary with a wide variety of professionals constituting the public health team. Team members can include statisticians, demographers, economists, nutritionists, sociologists, nurses, and so on.  Several other groups like occupational health physicians, ergonomists, health and hospital management graduates, para-medical staff, public health engineers, and environmental health experts also play a vital role in completing the public health team. Although practitioners of public health are familiar to this reality, this reality rarely (if ever) dawns to a student who is confined to a hospital for a major duration of his education. Public health problems can rarely, if ever, be compartmentalized as exclusively biomedical. There are not just multiple causal factors for a health state and several approaches toward tackling the problem, but also a myriad interplay between numerous disciplines while addressing public health problems. Decisions like adopting a new vaccine at the state level are not driven by mere disease-related concerns (exceptions like life-threatening diseases and epidemic situations notwithstanding), but are also influenced by cost-effectiveness and social acceptance, with a high reliance on health promotional activities.
Balancing the need for specialization in specific areas of PHE while preserving core public health ideals
Currently, the postgraduates are expected to function as effective public health managers, academicians, researchers, and health activists. As early as 1982, it was suggested that three such broad channels at the undergraduate level can be identified,  say for a family doctor, the specialist, and the health scientist; thus making it possible to plan manpower supply to fulfill the needs of a region or a state. World over (as far as research is concerned), there is a steady shift with specialists leading the way rather than generalists. A rapidly developing research stream with constant advances has made it impossible for researchers to stay updated in all areas, and hence encouraging a focus into a defined area. While it is acknowledged that generalists must constitute the vast majority of the public health workforce, it is equally correct that there is a need for focused researchers in some specialist areas. Epidemiology, biostatistics, nutrition, health promotion, health management, and health economics are a case in point. Our teachers will have to keep pace with these developments and the community medicine departments will have to be equipped to deliver these skills either as part of their regular programs or through special programs. The recently initiated masters programs in public health could offer specialized trainings in these streams.
Faculty in community medicine departments
The quality of teaching and the faculty strength are important determinants in maintaining high standards of PHE. Faculty development is an important issue that must be addressed in order to correct the wide variations in the level of PG training in public health. A critical issue towards improving the quality of teaching is that of strengthening the capacity of the faculty in Indian medical schools.  National teacher training centers (NTTC) can play a vital role toward achieving this objective. The number of medical education units has increased rapidly after 1997, with their main activities including the conduction of workshops targeted at medical teachers. The transformation from a teacher training into professional development by adopting interactive techniques of training, strengthen evaluation and promote research through a multi-pronged approach has also been recommended. 
The number of postgraduates produced annually is deficient as noted earlier and efforts to boost training capacity must be instituted in the near future. However, in order to increase the student capacity, we will have to examine whether the departments have adequate number of teachers to train additional postgraduates in accordance with the Medical Council of India norms. How do we proceed to address this issue? One solution toward improving the faculty strength is through sanctioning new teaching positions while strengthening the related infrastructure.  In the short run, even if faculty positions are made lucrative for new postgraduates, this will decrease the number of postgraduates available for health programs. It is unclear whether we should continue to adhere to strict teacher-postgraduate student ratio or relax it, while ardently hoping that the higher number of successful postgraduates would eventually fill the vacancies in community medicine. Liberalizing the teacher-postgraduate student ratio could be expected to negatively affect the quality of teaching. This governance issue needs a wider debate among academicians and practitioners, and needs to be debated among public health associations. The current scenario in the basic sciences departments of medical collages is a case in point, with most departments suffering from a severe crunch in the number of qualified teachers. Community medicine departments do not suffer from the acute shortages experienced by these basic sciences departments. In addition to increasing the quantity of teachers, we also need to pay equal attention toward the issue of quality of the teachers recruited to alleviate the shortage of postgraduates. Both a severe numerical inadequacy and poor quality of teachers have the potential to severely compromise the academic teaching.
Building skills of existing faculty members to cover emerging areas
Approaches include building skills and capacity of existing faculty members versus inclusion of non-medical public health specialists in schools of public health. While discussing the merits and demerits of such a choice are beyond the scope of this paper, there are definite measures that can be pursued to encourage existing faculty members to engage in personal and professional development. Preferential entry to formal educational courses is available for in-service medical professionals in some states. This facility can be extended to cover teachers in medical colleges in addition to their existing professional qualifications. This sabbatical would provide an opportunity for the teachers to develop and pursue academic and research interests at regular intervals. Opportunities for sabbaticals are an accepted perk for public health specialists in developed countries, but are not universally available in India. There are additional opportunities for professional development through distance-learning programs. Several reputed schools of public health in developed countries and some Indian institutes offer distance-learning opportunities. Recognizing the difficulty of reliving a large number of teachers for sabbaticals, an institutionalized opportunity to enroll and pursue these distance-learning courses can be considered. The current system permits a teacher to "qualify" the label of an expert only through undertaking a focused research and activity in the area. The opportunity for professional development can shorten this duration through providing an enabling learning environment for the teachers while still engaged in academic teaching.
Partnerships in PHE
Conventionally, Community Medicine departments have partnerships with communities as a part of field activities at the Rural Health Training Centre/Urban Health Training Centre. They may engage with non-governmental organizations and the health system for the delivery of interventions, along with development partners and other academic institutions (local, national and international) for academics and research. Collaborative activities in PHE are much more complex with the need for institutes to share and participate in complementary programs across different universities. Exchange programs between Indian institutes are an exciting prospect. They open the door for academicians to travel and study academic programs in different environments. The partnership and experience sharing between academic institutions provide for an opportunity to learn from the successes (and failures) of programs and institutes, and quickly replicate successful experiences using the model adopted by the partner institute. Such networks can also provide academicians with opportunities to visit and study the health system in different states of the country and permit wider professional networking (with overall benefits far exceeding just the academic benefits). Within-country partnerships can even be sought with technical institutes like the IITs and IIMs for issues in healthcare technology development and health management. Networking platforms like those offered by the National Institute of Health and Family Welfare and India PHEIN need to be subscribed and supported in order to rewardingly emulate the success stories. Professional associations like the Indian Public Health Association and the Indian Association of Preventive and Social Medicine can also provide wider opportunities for experience sharing. The associations can support academic partnerships and experience sharing between institutes from different regions of the country during their annual conferences. Academic sessions on PHE can also be a regular feature of the conference schedules for both these associations where important academic issues can be debated by a large group of teachers and students.
Community medicine departments are an opportunity to extol community-based education rather than institution or hospital-based education. The departments can ideally offer a skill and competency-based curriculum, integrating the disease pathology, the case-management and disease prevention/ control. A synergistic interaction between different academic subjects is possible in the community setting and these can be coalesced within the community setting during internship and PG studies. All community medicine departments and their students will benefit by the presence of strong field connectivity. Faculty numbers and skills need to be under a constant scrutiny, as deficiencies in either would negatively impact the quality of departmental functioning. Overcoming these deficiencies through a mixture of creating new positions and professional development of existing faculty can be examined at various levels. Avenues for academic collaborations need to be explored through pre-existing frameworks at the national and regional levels.
Recognizing the important role played by the community medicine departments, it is necessary to ensure that they continue to positively influence public health activities across the country in the changing scenario of PHE in the country. The solutions offered are not entirely novel. Efforts toward implementing some have been initiated in bits and pieces across the country and some efforts toward achieving them have already been instituted. Encouraging results however need prompt replication, with inter-institutional networking holding the key to wider dissemination and adoption. The way ahead for medical education in India was well summarized by Tessa Richards in the British Medical Journal as early as 1985.  "The need to change the undergraduate curriculum has long been recognized in Indian medical circles. To abandon the old British model with its ivory tower approach (now out of vogue even here) in favour of less autocratic methods of teaching and a more practically orientated course. To give the students a better appreciation of the prevalent diseases and health care problems in India and give them a realistic idea of how these may best be managed with limited resources."
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