B S GARG Prof & Head Dept. of Community Medicine MGIMS, Sewagram DHANWANTARI ORATION.

B S GARGProf & Head

Dept. of Community MedicineMGIMS, Sewagram

DHANWANTARIORATION

Dhanwantari is the physician of the Gods.

He arose after a long drawn and difficult process of churning of the ocean by the Gods and the demons, holding the cup of Amrita, the Elixir of Life.

This signifies that the task of achieving quality involves a number of difficult, yet necessary processes. “Accreditation is one such process aimed at achieving quality in education”

According to the English dictionary,

Accreditation implies:

official recognition,

general acceptance,

assurance of quality.

Accreditation is required Accreditation is required due to: due to:

A.Changing public expectations from doctors.

B.Globalisation and international standards.

C.Diversity in medical education.

D.Moves towards international standards.

A. Changing public expectations of

doctors: Mystique of medicine

Newspapers Books Radio Television Internet

“The public expectations of doctors is changing. Today’s patients are better informed. They expect their doctors to behave properly and to perform constantly well, and are less tolerant of poor practice.”

Sir Donald Irvine, GMC President.

B. Globalisation and international standards

The world is shrinking:

Liberalization of economyTelecommunicationsMore travelsAccess to mediaCyberspace

The commission on macro-economics and

health (WHO):

Extra expenditure of $27 billion on healthby the rich world in the poor world couldsave eight million lives a year – and boostthe global economy.

- BMJ, 5th Jan. 2002.

Social changes:

Education Wealth Innovations Human rights Concept of

quality

International standards:

Aviation Banking Telecommunications Environmental protection Food safety Human rights

International agreements (e.g., GATS 1994):

Global mobility

Common educational standards

Mutual recognition

Medicine is a global profession:

Medical ethics are common.

Medical knowledge has no national boundaries.

Public health physicians are trained in one country and provide service in different countries.

C. Present diversity in medical education

Over 2,000 medical schools

Curriculum appear similar but contents?

Outcome of educational efforts?

General medical council, U.K. 1993 report:

Revised the standards of undergraduate curriculum.

Move away from traditional all embracing curriculum.

Publish a White Paper on Public Health in 1999

Modern two-fold approach – core curriculum.- Special study modules.

UNITED STATESUNITED STATES

Guarantees equal standards for medical doctors graduating from all 144 medical schools.

The Council of Education for Public Health assists in accreditation of schools of public health, and public health programme

AUSTRALIAAUSTRALIA

1985, Accreditation Committee of the Australian Medical Council (AMC) established.

Until then recommendations of GMC, U.K., were used.

LATIN AMERICALATIN AMERICA

Pan-American Federation of Association of Medical Schools (PAFAMS), 1962 and National Association of Medical Schools developed accreditation standards.

Today in Latin America, the quality of medial education varies from “excellent to poor.”

MALAYSIAMALAYSIA

Attempts to develop an accreditation system based on USMLE.

CHINACHINA “Teacher centred” curriculum.

Very recently attempt to modernise medical education process.

Accreditation system for medical school programmes introduced.

MEDICAL COUNCIL OF INDIA

Regulation and monitoring of standards

Medical Education.Amendments to IMC Act 1956 on 27th August 1992 to restrict:

- Mushroom growth of medical colleges.- Increase of seats in courses.

- Starting of new courses. Accreditation Plans on the way

D. Moving towards international

standards in medical education:

Recent initiatives: The World Health Organisation (WHO). The Institute For International Medical

Education (IIME). The World Federation For Medical

Education (WFME).

International Standards must be: Capable of description. Meaningful. Appropriate. Relevant. Measurable. Achievable. Accepted by the users.

Standards must be:

Practical.

Recognise diversity.

Foster adequate development.

Advantages of internationally accepted standards:

Provide a basis for national evaluation of medical schools.

Develop consensus about objectives. Define core medical education. Broaden opportunities for educational

research and development. Empower educators to bring about change.

Save time for curriculum planners.

Provide valuable orientation for fund providers, politicians and society.

Facilitate exchange of medical students.

Easier acceptance of doctors in other countries.

Enhance quality of health care nationally and internationally.

The standards are structured The standards are structured according to nine areas:according to nine areas:

1. Mission and objectives.2. Educational programme.3. Assessment of students.4. Students,.5. Academic staff/faculty.6. Educational resources.7. Programme evaluation.8. Governance and administration.9. Continuous renewal.

Do Public Health Institutions Need Accreditation?

Needs based health system

Policy makers

Health Managers Health professionals

Communities Academic institutions

The WHO publication, Towards Unity for Health (October 2001) places academic institutions firmly in the Partnership Pentagon, designed for greater social accountability. The public health departments of such institutions , due to their close association with the community will have to play a leading role for ensuring accountability.

The status of Public Health discipline in India is not satisfactory. It has not been able to attract attention of politician, bureaucrats & other policy makers.

The discipline also doesn’t enjoy a respectful position amongst medical fraternity. The situation of the Departments of Community Medicine in medical colleges and state & district training centres as well as National institutes is far from satisfaction & we somehow have failed to deliver the desired effect.

The training and education of future public health professionals is largely out of tune with the health needs of the communities, which these professionals are destined to serve.

The main challenges for public health institutions in India are to:

reflect social responsiveness/social accountability,

developing quality assurance,

keeping pace with advancing technology

developing an interface with the community & 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.

In last few years – mushrooming of medical colleges without adequate need assessment & feasibility study.

These colleges have political & corporate patronage.

Accreditation will help in improving the quality of medical education in such situation.

IAPSM & MCI & GOI should respond to WHO program for Global accreditation.

The purpose of accreditation is to develop a system to determine and certify the achievement and maintenance of minimum desired standards of public health teaching.

The main purpose of public health teaching institutions is to prepare future generations of health providers to efficiently address community health needs. The advent of globalization and the open market economy calls for certain levels of competency as the public health speciality has to play a central and integral role in overall development.

On the negative side, accreditation is geared to detect deficiencies and give opportunity to rectify while promoting further development and safe guarding the public. Public health institutions have the closest links with the community, hence the necessity of “safe guarding the public”.

A framework for accreditation would therefore encompass: Elements related to the impact of public health institutions &

medical education on career choices of graduates, on the

work of medical profession and the on performance of the

health system.

It should also consider the capacity of public health

institutions to demonstrate the 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.

The accreditation in Public Health is required for the following:

Courses & Training programmes offered by Public health institutions for paramedical personnel. Short term courses & regular programme for training of Health workers (Male & Female), Public health Nurses, sanitary Inspectors & health educators etc.

Medical & Nursing Schools offering undergraduate & postgraduate courses as per recommendations of MCI & Nursing Council of India.

National, State & District Health & Family welfare Training Centres providing in-service training.

CME programmes by professional bodies & National academy of Medical Sciences.

THE CALCUTTA DECLERATION:

The Regional Conference on Public Health in South East Asia, organized by WHO in 1999 at Calcutta, drew attention to the state of public health education in the region and helped realize the need for an accreditation system. The following strategies were endorsed:

• Promoting public health as a discipline and essential requirement for health development

• Recognizing the leadership role of public health in formulating and implementing healthy public policies

• Creating career structures at national, state, provincial and district levels

• Strengthen and reform public health education, training and research

Regional Consultation on Development of Accreditation Guidelines For Educational Training Institutions And Programmes in Public Health-Chennai 31 Jan- 2 Feb 2002

Recommended strengthening of Human Resources Development in Public Health through education,Training & research.

Develop or strengthen existing regulatory bodies for accreditation of all institutions contributing education & training of Public Health personnel.

Recommended use of guidelines developed at the Consultation to develop National standards for Accreditation.

The global conference on international collaborationon medical education & practices Illinois, USA in 1994 urges

“that the priority concern be focused on the interface ofhealth care, medical practice and health professional education so that there is ready & coordinated responsiveness to societal needs.”

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.”

MILESTONES IN THE DEVELOPMENT OF ACCREDITATION SYSTEM FOR PUBLIC

HEALTH INSTITUTIONS IN INDIA

MCI Guidelines for Medical Education, including public health departments in medical colleges

Initiation of ROME in 1977

Established systems in USA, UK, Canada, Australia

Calcutta Declaration, 1999

Regional Consultation at Chennai, 2002

Acceptance by Public Health Institutions, Professionals ?

Effective Implementation strategy ?

Su Delong had this to say at the Eighth Regional Meeting of Directors or Representatives of School of Public Health in Bangkok in 1979: 

“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).

“ 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”

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 & they may be refined further in order to develop an effective & 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 behavioral 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 programme.

•Role of Skills

The institution must ensure that students acquire knowledge of Epidemiology & Public Health Management Sciences and skills (including communication skills) necessary to assume management responsibility upon graduation.        

• 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

•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 & field practice areas etc.

• Pedagogy Expertise: The institution must have a policy on teaching, learning methodology and 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 analyzed in relation to the curriculum.

• Organizational 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 reputed NGOs.

• Continuous Renewal of the School: The institution must be dynamic through the initiation of programmes and procedures for regular reviewing and updating of fundamentals of the institution, its structure and activities.

There is need to identify the different situations for community based training which may differ for different situations and levels of expertise. The need is to identify such centers and equip them for the learning processes.

If community based Education has to be adopted then all training institution should be linked to the health care system. A field practice area should also be developed for hands on experience & for developing essential skills.

Teaching / learning methods

We have to create an environment for learning involving an active process in order to prepare the person for life long education. It should also be based on a participatory approach.

Most of education of public health is didactic & within the four walls of the ivory tower like institutions with limited exposure to community.

It should be more active, inquiry driven and evidence based, with emphasis on problem solving

SOCIAL RESPONSIVENESSSOCIAL RESPONSIVENESS:

A measure by which an institution responds to societal needs- perceive the needs & reacts.

SOCIAL ACCOUNTABILITY: A Step ahead –institutions consult society to jointly identify priority health issues & expectations.

Accreditation and Social Accountability

Social Accountability can be assessed by four essential Reference points as fundamental values for the health system developmentQuality

Equity

Relevance

Cost effectiveness

The 48th World health Assembly in 1995recognized that both medical practice and education need to be reoriented to achieve relevance, equity, cost-effectiveness and quality.

RelevanceHighest

Highest

Cost- effectiveness

Quality EquityLowest

HEALTH COMPASS

These values should be tested for three basic

functions while accrediting public health institutions:

Teaching

Research

Services

These functions may be tested by a social accountability grid.

CostEffectiveness

Relevance

Equity

Quality

ServicesResearchTeaching

DOMAINSVALUES

The Grid may be expanded by further dividing

each Domain into three phases-

Planning- the way a medical institute demonstrate the accountability by means of mission statement or the ways the resources allocated or the departments organized.

Doing- demonstrate the action on plans.

Impacting- the institute demonstrate its contribution to important & sustainable changes in the health system, as a consequence to its capacity for advocacy to policy makers, heath delivery system, health professional or the community of users.

““80 years ago William Osler, the great physician and 80 years ago William Osler, the great physician and

educator told an undergraduate medical class that he educator told an undergraduate medical class that he

had good & bad News for them. The good News was that had good & bad News for them. The good News was that

half of what they had been taught would be out of date in half of what they had been taught would be out of date in

10 years. The bad News was that no one knew which 10 years. The bad News was that no one knew which

half.”half.”

Public health is also rapidly changing and evolving. Public health is also rapidly changing and evolving.

To cope up with the change it is necessary for public To cope up with the change it is necessary for public

health institutions to introspect and reorganize.health institutions to introspect and reorganize.

Hence, the need for a quality assurance system.Hence, the need for a quality assurance system.

Quality Assurance encourages moving towards

ideals as well as acknowledging reality, which vary

from country to country.

ACCREDITATION & QUALITY ASSURANCE

AccreditationQuality

Assurance

The processes of Quality Assurance & accreditation are very similar, yet different. Each is concerned with teaching, learning and assessment. The difference is essentially in the perspective from which these issues are analyzed and evaluated.

Accreditation is concerned primarily with standards.

Quality Assurance is concerned with “fitness for purpose”

Both are complimentary processes but a “marriage of the two” is required for ensuring social accountability.

Conceptual Framework of An Accreditation System for Public Health Institutions in India

National consortium for Accreditation

National Database(for universal access)

Pool of experts Standards

Assessment

Documentation

Institutional development

Networks, Associations (IAPSM)

Medical education is not completed at

medical school: it is only begun.

William H Welch. 1850-1934.

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 institutions. 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? 

Another important challenge is to establish that accreditation satisfies the need for social accountability.

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.

The issues needed to address the challenges

(1) Appropriate Training of Professionals in Public Health

(a) for both - DPH &

- MD

Each medical college must have at last 3 PHC’s

(b) National Institute should be reorganized.

(c) IAPSM has to play a pivotal all.(2) Job Opportunities for Public Health Specialists.

The posts which require public health specialization like – BMO, DHO & DGHS.

(3) Health Information System improvement is required urgently as at places it is absent or inactive.

(4) Integration between Curative Services & Public Health.

In 1979 Professor C.C.Chen of west China University visited a series of N American medical schools of public health. He had this comment to make:

“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”.

For IAPSM:• Establish a mechanism for reviving current status of all Public Health training institutes using evidence- based criteria in relation to numbers, distribution, career advancement opportunities etc.;• 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.• Develop partnerships with other government sectors, NGO’s, private organizations, and the community in developing PH services and training institutions;

For GOI/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.