Social accountability as a concept is becoming increasingly familiar to the Indian public. It spells out what society could legitimately expect from different services. Thus it challenges the service providers to explore and enhance their social contribution. It also empowers society to make the service providers answerable for deficiencies in service. This leads to the actualisation of desirable social objectives. Thus the social accountability approach can be fruitful in examining a problematic social service like health-care delivery.
There is little need here to elaborate on the deficiencies of our health care system. The health-care deficit in India is a matter of daily distressing experience. But this intractable crisis in health care, which is a matter of life and death to individuals and cripples the nation, does have effective, though not perfect, solutions. These call for changes both in the way health-care delivery is organised and the way medical care itself is practised.
This article aims to explore the applicability and implications of social accountability in one important component of health-care delivery, namely, medical education. Can modifications in medical education contribute to the equitable, affordable and effective health care that should mark a healthy society? Countries like Cuba and South Africa have demonstrated how medical education can be modified to this end. If so, can this privileged and almost sacrosanct segment of professional education be held accountable to society?
Unlike many other professions, a major part of doctors' education occurs in institutionalised practice situations with close mentoring by practising role models. This long period within the walls of medical colleges sets the prism through which their graduates view their profession. And their perceptions are self-perpetuating because they profoundly influence society's own understanding of what constitutes “good” health care.
In a landmark publication on “Social Accountability of Medical Schools” (1995), the World Health Organisation identified four core values that socially responsible medical colleges should embody and disseminate: relevance, quality, cost effectiveness and equity. If medical education can be reoriented towards these four values, gradually the medical profession will come to practise them. But Indian medical colleges now focus almost totally on quality, or “uniform standards” as defined by specialist-oriented tertiary care. They do not emphasise competencies required for medical practice. The lack of basic skills undermines the confidence and the inclination of physicians to successfully practise after graduation in settings of primary care and secondary hospitals which are alien to them. And these precisely are the settings where India's health-care system is most at fault.
Rethink among educators
Recent events have raised hopes of some salutary developments, within the medical fraternity and among the general population. The reconstitution of the erstwhile Medical Council of India (MCI), the proposed National Council for Human Resources in Health (NCHRH) Bill, and attempts to restructure the core medical curriculum set the stage for this optimism. There is ambitious talk of having a medical college in every district. It was in this context that educators in the health professions from across India came together recently at the second National Conference on Health Professions Education in Vellore. This conference broke new ground by choosing as its theme “Socially accountable health professions education.” Their Concluding Statement (The Hindu EducationPlus, Tamil Nadu edition, October 24) made a set of comprehensive recommendations to medical colleges, the Medical Council of India and the Ministry of Health and Family Welfare so as to align medical education “consciously towards improving health and health-care provision for the people of India.”
The basis of their road map for change is that the learning environment of future doctors should encompass all the links in a model health-care system extending beyond the present teaching hospitals to secondary-level hospitals and primary health centres. The setting of their training should convincingly demonstrate how all the levels of health-care work together to provide optimal care to the community. For this, medical colleges will need to develop formal and effective linkages with the local district hospital, taluk hospitals and primary health centres, and also be responsible for the health of a defined population. Medical college faculty members should be engaged in teaching and clinical care at all these levels. Suitable health-care professionals in the health-care system should also be involved in the training programme. In their research activities too, the colleges should give preferential attention to analysing and addressing the health issues of the local community.
Admittedly, these call for breaking new and difficult ground. In the state-run medical colleges, the Directorate of Medical Education and the Directorate of Health Services will have to work together to make these possible. In the proliferating private medical colleges, public-private partnerships will have to be worked out to provide optimal health care to chosen communities.
Graduates of such a training programme grounded in the Indian realities will be able to serve as competent basic doctors in the health-care system. The nation should avail of their contribution to solve the pressing health-care needs through a period of compulsory service immediately after graduation. Continuing Medical Education programmes should be on offer for further professional development of the graduates during this period. As the academic discipline undergirding professionally sound generalist care, every medical college should have a Department of Family Medicine and offer postgraduate training in this discipline.
The way forward
How can medical colleges be held socially accountable in the likely scenario of rapid expansion of undergraduate and postgraduate medical education in India? About a third of our medical colleges are already in the private sector. And further growth of medical education is likely to be mostly in the commercial segment that aims to make a profit out of offering entry into this lucrative profession. In their services too, they would prefer to concentrate on the upmarket “plums” in specialist tertiary care. In such a context, only a regulatory system committed to social accountability can ensure the desired changes.
Therefore, in the proposed NCHRH Bill, the new Council should be mandated not only to ensure uniform and high standards but also to make medical education socially accountable for addressing India's heath needs. Our experience with enforcing social obligations in other sectors (for example, the telecom industry) highlights the difficulties of implementing such mandates. In order to ensure the required commitment to a social as well as professional mandate, it is particularly important that the new NCHRH should have a broad representation to include all stakeholders, and not just the leading lights in the health professions. Far-reaching as these proposals are, the impending changes in the regulatory framework offer a window of opportunity to ensure social accountability in medical education, and to actualise the vision of equitable, affordable and effective health care for all people.