|Year : 2022 | Volume
| Issue : 1 | Page : 11-17
Innovative Strategies in Medical Education for Addressing Gaps in Health-Care Service in Rural India
Department of Community Medicine, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, India
|Date of Submission||29-Oct-2021|
|Date of Acceptance||15-Feb-2022|
|Date of Web Publication||29-Apr-2022|
Dr. Bratati Banerjee
Department of Community Medicine, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi 110002
Source of Support: None, Conflict of Interest: None
At least half of the world’s population still do not have full coverage of essential health services and the available health-care services are also not equitably distributed, the rural areas being the generally underserved ones. Several factors influence attraction and retention of doctors in rural areas which are related to international and national contexts, work-related factors, environmental and living conditions, and individual or personal factors which includes family and social support, in addition to personal aspirations. Innovative strategies have been worked out and implemented to address these problems and fill the gaps in the areas of educational, regulatory, financial and professional and personal support. This review discusses the educational strategies which are targeted at all levels viz. selection of candidates for admission, and subsequent undergraduate, internship, and postgraduate teaching and training that can be oriented toward rural health and health-care services
Keywords: Medical education, retention of doctors, rural health care
|How to cite this article:|
Banerjee B. Innovative Strategies in Medical Education for Addressing Gaps in Health-Care Service in Rural India. MAMC J Med Sci 2022;8:11-7
|How to cite this URL:|
Banerjee B. Innovative Strategies in Medical Education for Addressing Gaps in Health-Care Service in Rural India. MAMC J Med Sci [serial online] 2022 [cited 2022 Aug 19];8:11-7. Available from: https://www.mamcjms.in/text.asp?2022/8/1/11/344349
| Introduction|| |
Focus across the globe is currently on Universal Health Coverage (UHC) that enables everyone to access the services addressing the most significant causes of disease and death, and ensures that the quality of those services is good enough to improve the health of the people who receive them. All countries are committed to providing UHC to their citizens. However, at least half of the world’s population still do not have full coverage of essential health services.
The available health-care services are also not equitably distributed. Half the world’s people currently live in rural and remote areas. On the contrary, most health-care workers live and work in cities. This leads to imbalance between the need for health care and the available health-care services. Such imbalance is common to almost all countries and its impact is most severe in low-income countries. This is because many of these countries already suffer from acute shortages of health workers in all areas and the proportion of the population living in rural regions are more than that in urban areas thus raising the requirement in the former more than the latter. The difference is more marked in poorer countries than in rich ones.
India still has a shortage of physicians. The current estimated physician-to-population ratio in India is 1:1700, against a target of 1:1000. Most doctors (74%) work in urban areas. There are 0.2 beds/1000 population in rural areas when compared with 1.1 beds/1000 population in urban areas. There is a shortage of doctors in government health centers in rural areas when compared with urban areas with the density of physicians in rural India at 3 per 10,000 population against 13 per 10,000 in urban areas. There is also an overall shortage of medical colleges in rural areas, with only slightly more than one-fourth of the rural districts across the country having a medical college.
| Rural Health-Care Services|| |
Though there is considerable difference in the health-care situation between developing and developed countries, the main challenges in rural health are the same around the world. Availability and accessibility are the major problems; as in all countries, the resources are concentrated in the cities. In addition, there are difficulties with transport, communication, services, and resources, along with shortage of health-care providers in rural and remote areas all over the world.
Main challenges faced by rural practitioners are that they have a heavier workload and are required to provide a wider range of services with more clinical responsibility and in a situation of professional isolation. Hence, merely producing more health-care providers and expecting the excess human resources to spill over from the urban to rural areas as an overflow effect, do not mostly happen and hence the crisis remains. Rather, professional dissatisfaction often ultimately leads to internal and many times international migration.
| Guidelines of the World Health Organization|| |
In the year 1976, the Regional Committee for South East Asia of World Health Organization (WHO) noted that a large majority of doctors are not trained and equipped to meet the needs of the community in the matter of preventive, promotive, and curative health-care services, particularly for the rural areas. It was also noted that the trainings were hospital based, making the trainee doctors dependent on sophisticated aids and diagnostic services, with very little exposure to rural conditions. With a call for Reorientation of Medical Education (ROME), it was emphasized that doctors produced by medical institutions should be as close to the community as possible to make them capable of working in real-life situations in rural areas. To enable implementation of this process, the WHO assisted all governments of the regions in the reorientation processes so as to make medical education develop closer links with the community and to inculcate in the trainee doctors an interest and willingness to provide services to the rural community.
The Sixty-third World Health Assembly in May 2010 adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel, which offers a framework to manage international migration over the medium to longer term. Following this, the WHO has drawn up a comprehensive set of strategies to help countries encourage health workers to live and work in remote and rural areas, which is a tool that can be used to address one of the first triggers to internal and international migration, that is, dissatisfaction with living and working conditions in rural areas. The two tools together, that is, the code of practice and these new guidelines provide countries with instruments to improve workforce distribution and enhance health services. Doing so will address a long-standing problem, contribute to more equitable access to health care, and boost prospects for improving health-care services and consequently improve health status of the population.,
| Factors Influencing Attraction and Retention of Workers|| |
Multiple complex and interconnected factors have been reported to influence a health worker’s decision to relocate, stay, or leave a post in rural or remote areas. Broadly these can be linked to the individual’s characteristics and preferences, health system organization, and social, political, and economic environment. Although these factors are specific to the situation and context, there are a common set of issues observed everywhere. These commonly reported factors include:
- Unsuitable preservice training for practice in rural and remote areas
- Lack of opportunities for further training and career development
- Low salaries
- Poor working environments
- Limited availability of equipment and drugs
- Inadequate management and unsupportive supervision
- Insufficient family support
These factors have been described either as “pull” or as “push” factors. The “pull” factors are those that attract health professionals for a particular post, facility, or location which are higher income, improved working and living conditions, etc. The “push” factors are those that may influence the health professionals not to take up a post in a remote location or not to continue the service which include poor working conditions, lack of opportunities for academic and career growth, lack of family and social support, etc.
These factors can be broadly categorized as those related to international and national contexts, work-related factors, environmental and living conditions, and individual or personal factors which includes family and social support in addition to personal aspirations. The broad categories are depicted in [Figure 1].
|Figure 1 Factors influencing attraction and retention of workers (Ssource: 7).|
Click here to view
Various studies have consolidated many factors to reveal three ultimate areas more strongly associated with entering rural practice. These are:
- a rural background;
- positive clinical and educational experiences in rural settings as part of undergraduate (UG) medical education; and
- targeted training for rural practice at the postgraduate (PG) level.
| Evidence-Based Strategies|| |
Research has been undertaken across the world to design, implement, and evaluate innovative strategies to overcome the imbalance by improving retention of health-care providers in rural areas, by addressing all the identified factors. All evidences have pointed out the fact that a single intervention is unlikely to be successful and hence interventions are to be implemented in bundles, combined in different packages according to the country’s socioeconomic context and characteristics of the health workers. These areas are outlined in [Figure 2].
|Figure 2 Categories of interventions used to improve attraction, recruitment, and retention of health workers in rural areas (source: 2).|
Click here to view
A decade after developing the strategies for attraction and retention of health workers in remote and rural areas, WHO launched a synthesis of recent evidences to see what has worked, and what has not, to attract, develop, recruit, and retain health workers in rural and remote areas, through another systematic review. The findings of this systematic review have been consolidated into various categories of interventions and based on this evidence, the WHO has drawn up a detailed and comprehensive set of strategies to help countries encourage health workers to live and work in remote and rural areas. These have been enumerated in the following sections.
- Use targeted admission policies to enroll students with a rural background in education programs for various health disciplines, to increase the likelihood of graduates choosing to practice in rural areas.
- Locate health schools, campuses, and family medicine residency programs outside of capitals and other major cities, as graduates of these schools and programs are more likely to work in rural areas.
- Expose UG students of various health disciplines to rural community experiences and clinical rotations as these can have a positive influence on attracting and recruiting health workers to rural areas.
- Revise UG and PG curricula to include rural health topics so as to enhance the competencies of health workers in rural areas, and thereby increase their job satisfaction and retention.
- Design continuing education and development programs that meet the needs of rural health workers, which are accessible from where they live and work, so as to support their retention.
- Introduce and regulate enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction, thereby assisting recruitment and retention.
- Introduce different types of health workers with appropriate training and regulations for rural practice to increase the number of health workers in rural and remote areas.
- Ensure that compulsory service requirements in rural and remote areas are accompanied with appropriate support and incentives, so as to increase recruitment and subsequent retention of health workers in these areas.
- Provide scholarships, bursaries, or other education subsidies with enforceable agreements of return of service in rural or remote areas to increase recruitment of health workers in these areas.
- Use a combination of fiscally sustainable financial incentives, such as hardship allowances, grants for housing, free transportation, paid vacation, etc., sufficient enough to outweigh the opportunity costs associated with working in rural areas as perceived by health workers, to improve rural retention.
- Improve living conditions for health workers and their families and invest in infrastructure and services (sanitation, electricity, telecommunications, schools, etc.), as these factors have a significant influence on a health worker’s decision to locate to and remain in rural areas.
- Provide a good and safe working environment, including appropriate equipment and supplies, supportive supervision and mentoring, to make these posts professionally attractive, and thereby increase the recruitment and retention of health workers in rural and remote areas.
- Identify and implement appropriate outreach activities to facilitate cooperation between health workers from better served areas and those in underserved areas, and, where feasible, use telehealth to provide additional support to health workers in remote and rural areas.
- Develop and support career development programs and provide senior posts in rural areas so that health workers can move up the career path as a result of experience, education, and training, without necessarily leaving rural areas.
- Support the development of professional networks, rural health professional associations, rural health journals, etc., to improve the morale and status of rural providers and reduce feelings of professional isolation.
- Adopt public recognition measures such as rural health days, awards, and titles at local, national, and international levels to lift the profile of working in rural areas, as these create the conditions to improve intrinsic motivation and thereby contribute to the retention of rural health workers.
| Curriculum for Medical Education in Community Medicine in India|| |
Medical institutions play a stellar role in preparing doctors for providing health-care services to the entire community in both urban and rural areas. This is the social accountability that all medical institutions are committed to, which has been defined by the WHO as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and the nation that they have a mandate to serve”.
Allopathic system of medical education in India was initiated by the British, which was primarily urban oriented and was lacking in exposure to problems and health-care delivery system in the rural areas. In the year 1975, the Srivastava Committee recommended creation of paraprofessional or semiprofessional workers from the community itself to ramp up health care in rural areas. The committee further recommended establishment of a Medical and Health Education Commission for revision of UG curriculum, reorganization of internship training program, and also of PG education and research. Subsequently, the concept of ROME for rural training of the WHO was implemented in India in the year 1977 as the ROME Scheme to provide adequate rural exposure. Under this scheme, strengthening of rural training was proposed to be achieved by attaching one Rural Health Training Center with every medical college, with two other areas served by two Primary Health Centers for providing comprehensive primary health care. The medical graduates were to undergo training in these rural centers during their internship.
In keeping with the changing scenario, the UG and PG medical curricula in India were updated by the Academic Council of Medical Council of India, with the help of a panel of subject experts from across the country. It has subsequently been implemented across the country by the National Medical Commission, from academic session 2019 onwards for UG and 2020 onwards for PG courses. The new curricula provide effective outcome-based strategies with various domains of teaching and assessment, forming the framework of competencies., Community medicine being the main discipline that provides opportunity for exposure to rural health care, this discipline has been discussed here in the context of the new competency-based medical education (CBME) curriculum.
At the UG level, there is integration of the related disciplines, designed to give the students a holistic understanding of the various subjects so as to function appropriately and effectively as a physician of first contact., However, it may be observed that in the UG curriculum for community medicine, though focus has been laid on care of the community, there is conspicuous absence of the word “rural” in the goals or in the 107 competencies spread across 20 topics. In the PG curriculum for MD community medicine, out of 57 competencies in 4 domains − 34 cognitive, 3 affective, 12 psychomotor, and 8 miscellaneous competencies − only 1 competency in cognitive domain mentions describing Panchayati Raj System and 1 competency in psychomotor domain mentions conducting health education programs in rural settings. This reveals some lack of focus on rural health in the syllabus itself for both UG and PG course in community medicine, even after extensive revision.,
One important change in the new CBME curriculum for UG course is addition of elective posting, under which the student may opt to be posted at community clinics in rural settings. It may be noted that this is optional and rural posting may not be opted by the students for obvious reasons. Hence, this inclusion may not serve any ultimate purpose.
However, there is one excellent opportunity of rural exposure that is during Internship, when the students have to acquire learning experience in the community during mandatory posting in the Department of Community Medicine for 12 weeks, where the Intern will gain hands-on experience in Community Health Centre/Rural Health Centre.
| Strategies for Attraction and Retention of Doctors in Rural Areas|| |
Following the guidelines of WHO, India too has adopted several strategies over the years, to impart rural community-based training to medical UG students, which included the ROME scheme., Based on the recent WHO guidelines for attraction and retention of medical workforce in rural and remote areas, strategies have been worked out and implemented in India. The strategies adopted by the various states of the country can be classified into five broad categories.
- Educational and regulatory measures
- Monetary compensation
- Workforce management policies
- Public private partnership
- Multiskilling and alternative service providers
Of the various strategies, the educational and regulatory measures play major role in making the foundation and preparing the future health-care provider to serve in rural and remote areas, which will be discussed here through some examples of case studies.
| Innovative Strategies in Medical Education|| |
The problem with medical education is that it is a tertiary hospital-based model, mostly in an urban setting, which provides limited exposure to the future doctors about health needs and infrastructures of the rural areas. Medical graduates thus develop a preference to work in urban areas when compared with rural or remote areas. This can be minimized through educational and regulatory reforms at the national and state levels, by way of recruitment from rural areas, providing rural exposure during UG course, making rural service mandatory for medical graduates, and also by linking PG specialization with rural service. Three forms of this linkage exist: (1) pre-PG compulsion, that is, compulsory rural service for admission to PG programs; (2) in-service PG incentive, that is, giving incentives to in-service public sector doctors in PG admission or toward the cost of a PG degree; (3) post-PG compulsion, that is, compulsory rural service for all PGs. Some examples of such interventions being implemented are discussed in the following sections.
Recruitment from rural areas
In several states of the country, preferential selection of health workers with rural backgrounds for medical education is carried out based on the assumption that these health workers will be interested to serve and remain in their native areas. There are national- and state-level norms for reservation of seats for vulnerable social groups such as ST, SC, and other backward classes for all medical courses. For example, coaching institutes and scholarships for students from vulnerable social groups and rural/remote areas have been introduced in Chattisgarh to enable them to get admission in higher education, including medical education. Two such coaching institutes viz. Prayas Educational Institution in Dantewada district and Sankalp in Jashpur district have been set up.
Many states give preferential admission to candidates from rural or tribal background for the auxiliary nurse midwifery training program and nursing courses. One such model, the Swalamban Yojana has been started in the state of Madhya Pradesh in the year 2006 to 2007 where candidates with rural background are preferably selected and sponsored for the nursing courses and are bonded to serve in the rural area of Madhya Pradesh for 7 years after passing or pay a bond money. Similar model may be adopted for doctors too.
Implementation of ROME scheme
The Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram, is India’s first rural medical institute. It has been implementing its community-based public health teaching with the aim of training doctors for work with the rural poor. It orients students to the prevalent public health problems of rural areas and empowers students with the necessary social, medical, and public health skills through curricular innovations such as orientation camp for early students, social service camp in villages, a village adoption scheme, ROME camp, rural orientation during internship, and 2 years required rural service before graduates are allowed to pursue PG training at MGIMS. The camp is an integrated approach to public health and clinical disciplines, where the field clinics for students are arranged within the patient’s house. The camp curriculum focuses on primary health care and attempts to create conditions for the students to gain a hands-on understanding of the nature of rural health problems. Such community-based teaching for medical UGs is seldom practiced in India. Students are generally very positive about all aspects of the camp and its component parts. The major strength of the camp is its exposure visits and hands-on experiences in surveys and interaction with village-level health-care providers.
Compulsory rural service for medical graduates
Many states have made it compulsory for all the medical graduates to serve in rural areas for a duration varying from 1 to 5 years. Usually a bond is signed and the doctor can opt out of the rural service by paying a penalty equivalent to the bond amount. The bond amount ranges from approximately Re. 1 lakh in Chhattisgarh to Rs. 10 lakhs in Meghalaya.
Many states have made it mandatory for all the graduates to complete 2 to 3 years of rural service for admission to the PG degree programs. States such as Arunanchal Pradesh, Maharashtra, and Tamil Nadu have been implementing this policy for the past 15 years. About 10% to 30% of the PG seats are reserved for in-service candidates in Jammu and Kashmir, Nagaland, Orissa, and Tamil Nadu.
In-service PG incentive
Several states give certain benefits to in-service doctors working in rural areas for pursuing PG studies. These benefits are independent of any kind of mandate or compulsion. This benefit is being provided in different ways. In some states, for example, Andhra Pradesh, Assam, Chhattisgarh, and Gujarat, about 10% to 30% of the total PG seats are reserved for in-service doctors completing 2 to 3 years of service. In-service doctors take the entrance examinations but compete within themselves for the reserved seats which increase their chances of admission. In several other states, for example, Kerala, Mizoram, and Uttarakhand, preference is given to in-service doctors in the form of additional marks which can be added to the total marks obtained by the candidate in the qualifying PG examination. The number of marks given is according to the tenure and the location of service such as rural or tribal area. In some North-Eastern states, for example, Arunanchal Pradesh, Tripura, etc., in-service medical officers on completion of rural service are eligible to be sponsored by the state, which covers all expenses of their PG training.
In some states, for example, Tamil Nadu, Kerala, and Jharkhand, compulsory service is being implemented for students graduating from PG courses. Specialists graduating from government PG colleges have to sign a bond to serve in rural areas for 5 years, whereas specialists from private colleges have to serve for 1 to 3 years against a bond of Rs. 5 lakhs.
| Summing Up|| |
Intervention strategies that already exist or those which can be implemented may be summed up as follows:
- Background: Recruitment from rural areas
- National- and state-level norms for reservation of seats for vulnerable social groups for all medical courses
- Coaching institutes and scholarships for students from vulnerable social groups and rural/remote areas
- UG level: Implementation of ROME scheme
- Establishing Medical Colleges in rural areas for UG teaching and training
- Implementing community-based public health teaching with the aim of training doctors for work with the rural poor in line with ROME
- Internship training to impart-specific hands-on learning for health and health-related problems of rural areas
- PG level: Linkage of PG specialization with rural service
Pre-PG compulsion: Compulsory rural service for admission to PG programs
- In-service PG incentive: Incentives to in-service public sector doctors in PG admission or toward the cost of a PG degree
- Post-PG compulsion: Compulsory rural service for all PGs
| Conclusion and Way Forward|| |
Educational and regulatory measures play major role in making the foundation and preparing the future health care providers to serve in rural and remote areas. Focus should be placed on these aspects to inculcate the spirit of service to humanity especially in rural and underserved areas, through strategic interventions such as selection of candidates from rural areas; curriculum goals and objectives to include rural health explicitly; curriculum to incorporate teaching–learning methods in line with ROME; internship training to impart specific hands-on learning for health and health-related problems of rural areas; preferential selection of candidates for PG courses to be based on pre-PG rural background/rural service; in-service candidates with rural experience to be given benefit in competitive entrance examination; PG courses of all specialties to have compulsory short-term period of training in rural secondary care facilities; and post-PG rural service for short periods to be made mandatory for PG certification.
In addition to such strategies, focus should also be on developing primary-care physicians, family physicians, and multiskilled basic doctors, while considering aspiration of students too. Along with revamping the education system, workplace facilities and extension of academic and career development opportunities should also be made available to address all factors influencing attraction and retention of medical workforce.
Professional organizations can be involved in the process through advisory role by formulating proposals with innovative strategies for curricular innovations to provide rural experience; through providing service by adopting villages and organizing health camps for students which can be included within the curricula and additional points given in certifying and competitive examinations for UG and PG courses; and also through academic exposure by extending short-term fellowship programs and conducting regular CBME programs for service providers posted in rural areas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brahmapurkar KP, Zodpey SP, Sabde YD, Brahmapurkar VK. The need to focus on medical education in rural districts of India. Natl Med J India 2018;31:164-8.
] [Full text]
Strasser R, Neusy AJ. Context counts: training health workers in and for rural and remote areas. Bull World Health Organ 2010;88:777-82.
Web Annex A. GRADE evidence profiles. In: Retention of the Health Workforce in Rural and Remote Areas: A Systematic Review. Geneva: World Health Organization 2020.
Rao DK, Gupta G, Sundararaman T. Human Resources for Health in India. Strategies for Increasing the Availability of Qualified Health Workers in Underserved Areas. India: Public Health Foundation of India & National Health Systems Resource Centre; 2011.
Sundararaman T, Gupta G. Indian approaches to retaining skilled health workers in rural areas. Bull World Health Organ 2011;89:73-7. | doi:10.2471/BLT.09.070862
Dongre AR, Deshmukh PR, Gupta SS, Garg BS. An evaluation of ROME camp: forgotten innovation in medical education. Educ Health 2010;23:1-9.
Kumar R. Academic institutionalization of community health services: way ahead in medical education reforms. J Family Med Primary Care 2012;1:10-9.
[Figure 1], [Figure 2]