Need for a change in health professions’ curriculum and the concept of health city

 

 

Abstract               The modern health programs remains the same size as decades ago and is nowhere close to the growing health demands despite the alarming population expansion and emerging infections and diseases. A multidimensional approach while considering the various constraints the nation faces such as budget, large scale migration of potential workforce and lack of inter-professional coordination is necessary to cope up with the emerging human health needs. The health city concept aims to decentralize the focus from the tertiary systems to primary care focuses called health city. In addition to providing the basic health care services, it will also help resolve other key issues such as shortage of health professions’ manpower, inequity in the distribution of health professionals and lack of team-based approach. We also provide recommendations for training the physicians and the ways in which the health professionals’ curriculum can be incorporated into the health city concept. Addressing the work health force issues is extremely important to meet the changing needs of the health services.

Key Word: health city.

 

INTRODUCTION

Selflessness, sacrifice in one's personal life, long hours, dissatisfaction with governmental and other bureaucratic restraints, high costs in sustaining practice.... Having said all this, there is something more which drives the health profession - Altruism, dedication and more importantly a patient's trust...If u think I am talking about the today's health profession, then the answer is a big NO! All is not well by the 21st century. Despite the significant achievements in the field of health with a resultant rise in the human life span by 20th century, this century has left us incapable of facing the now burning health problems. This is evident as the collapse of the average life expectancy in some countries. The modern health programs still remains the same size as decade ago despite the alarming population explosion thus making the current staffing pattern and services just nowhere close to present day’s growing health demands.

• Looming of fresh health challenges:

The health security of all is under stake with the emerging infections and diseases unknown to the mankind. Rapid epidemiological and demographic transitions has only added to the burden giving no time for the health systems and medical advancements to cope up the emerging human health needs. Therefore, it seems extremely important to focus on the changing needs of health services. This convinces the necessity to master a new set of technical and cultural skills by the health workforce, while retaining their capacity to deliver the services that are being offered currently.

• Severe health workforce crisis:

The world health report 2006 "Working together for Health" has reported critical shortage of health professionals equivalent to a global deficit of 2.4 million doctors, nurses and midwives. This has left millions of people worldwide devoid of the essential healthcare and services that are desperately needed. Inadequate funding and unhappy salaries and benefits has discouraged the choice of public health as a promising career option. With very little progress being made to alleviate the shortages, a situation of unmet growing community need has arose with potential imperial to the public’s health. It is definitely surprising that the public is mostly unaware of the health workforce shortage and have different mindset with regard to the health systems and delivery. The National Association for Country to City Health Officials (NACCHO) have reported that the health departments face highest difficulty in recruiting public nurses, epidemiology and environmental health scientists. With the hiking health expenses and the unmet demands of the community’s health needs, it has become alarmingly necessary to address the health workforce issues. The recruitment of the next generation of public health leaders would be of great help to tackle this crisis with potential negative outcomes. The health departments fall shortage of varying cadre of health professional, to mention, the public health nurses being most difficult to recruit and retain. The fundas of sophisticated lifestyle and improved living conditions and comfort has somehow lead to the lack of enthusiasm of public health career. Mostly, it is the absence of clear career path and poor advancement opportunities that has imposed such a sense of insecurity. Similar shortage issues exists for workers with management and leadership skills. Contemporary public health issues has placed unfamiliar responsibilities to the public health managers. With the silent crisis of looming extrados of health professionals eligible for retirement , it is likely that a leadership vacuum will be created.

• Tribalism of health profession - the Medical Brain drain :

Despite educating adequate numbers of doctors and nurses, many countries today face a burning problem of health workforce migration, often called "the medical brain drain". Inability of the labour market to integrate them efficiently and unsatisfactory work conditions has lead to large-scale migration of the potential workforce leaving the health systems stranded. These migratory flows being poorly documented, makes planning and policy making at the national level difficult. The oversupply or undersupply of the health workforce though conventionally observed at the national level, shows alarming differences within the country as well. This unequal distribution of the primary care workforce is a bigger problem than the health professionals shortage per se. "An unequal distribution implies that many areas have relative primary care shortages, especially rural communities and areas of measurable social deprivations" states a recent policy brief from the Graham Center, USA. In India too the rural areas experience severe shortage of health care professionals impacting negatively on the health care provision while in urban locales , there is clustering of practitioners and more importantly the specialists. It is disappointing that the health professionals lack knowledge and formal orientation towards the public health. Much less attention is being paid to formal training to understand the public health systems and problems. With the acute shortage of public health workers, the ability to respond to the health crisis or to pursue population based strategy, such as health promotion becomes doubtful.

• Transforming health professions' education- A Multidimensional Approach :

Concerted and immediate efforts to transform and scale up health professions' education has now become crucial to respond to the ever changing and evolving needs of the population around the world. A mere increase in the number of health professionals would not suffice. It is necessary to ensure that they have knowledge and more importantly the skills and competencies to address the health-care needs of the community. The report by Gilles Dussault et al, "Assessing future health workforce needs" states that future needs are not expressed only in numbers, dimensions of work environment, such as the dimensions of work environment, such as the division ( skills mix) and organization of labour, competencies working conditions, productivity and quality targets are critical variables.

Analysis of the current situation of health workforce insufficiency and crisis threw light on the following realities:

• The health profession has taken a new dimension turning more profit oriented with the lack of enthusiasm for public health careers.
• The medical curriculum being linked to the tertiary health system leaves the students unexposed to the primary health settings.
• No proper measures to check the skills and efficacy of the graduated physicians .
• Very little inter-professional coordination and need for team based approach to patients.
• My perspective - the concept of Health City

For solving these aforesaid issues, we are in need of a multidimensional approach keeping in mind the various constraints the country faces like the budget. It is when the concept of health city came to life. In India, the current doctor to population ratio is approximately 1:1700 which is very much high compared to the required standards. Due to the present financial and man power constraints, I would like to propose the concept of health cities for every 3 lakh population. The health cities would serve the purpose of providing health care for the referral services offered by the Primary health centers. This simulates the Secondary level of health care of the present day health system. But they will mark a difference in that they would also serve as established sites for teaching and providing quality training to the medical and other allied health sciences students. The current recommendation is to train atleast about 100 medical undergraduates and nurses and 30 students of other health professions such as the community health worker, outreach personnel and other allied health sciences. Before understanding the proposed changes to the curriculum it would be wise to understand the hierarchy of the health system that would result by implementing the " Health City concept ".

~ Hierarchy of the health system in accordance to the health city concept

The main objective of any health system is to provide the basic primary health care services to the people which is the right of any citizen of the country. But in todays world, the health system as a whole is more inclined to the tertiary level of health care. This has only coerced additional burden on the health care providers who are already deficit in most of the parts of the country. The health city concept would decentralize the focus from the tertiary systems to what are known as the health cities. The health city would initially cover a population of 3,00,000. A cluster of primary health centers preferably 5 from the urban and 5 from rural areas would be under the supervision of a health city. The referral services provided by the primary health centre would be managed by the health cities. The health cities in turn would be under the control of district hospital. The hierarchy can thus be explained in a flow chat as follows:

Health apex of the state

District Hospitals

Health City

Primary Health Centre

Primary Health Centre (Urban)

Primary Health Centre (Rural)

~ Incorporating the health professions' education in the health city concept:

 The Medical Council of India clearly states that the primary aim of the medical undergraduate curriculum is to develop efficient primary care physicians. But the question is how much justice is being done to the objective. Not only in India, but a similar situation prevails in most of the developed nations of the world where the medical graduate opt for residency and fellowship programs paying little or no attention to the primary health care delivery. With a view to solve this critical problem , the concept of health cities proposes the idea of incorporating the health professions' education at the health city and primary health centre level i.e, at the primary and secondary levels of health care.

 The health city in addition to delivering the basic healthcare services would also serve as points of health professions' training. The setting would be entirely different from that of the present day systems.

Each health city would provide basic sciences and clinical education to a set of health professions under the same roof namely

• The physicians - they would serve the role of future primary care physicians.
• Nursing graduates
• Dentists
• Community health workers
• Outreach personnel
• Other allied health sciences and non clinical care providers.

Due to the shortage of resources and manpower, the number of graduates being trained in each health city shall be limited to 100. But, the outstanding merit of this proposal would be that it would help in developing inter-profession coordination greatly. This multidisciplinary team approach would also help to address the multifaceted problems and needs of the patient more convincingly. Thus taking the medical curriculum into consideration, the training of the physicians would be in the following 3 phases.

PHASE 1: 2 years of basic health sciences education at the health city.

PHASE 2: 2 years of clinical training along with learning the corresponding clinical curriculum at the health city.

PHASE 3: 1 and half years of exclusive internship program in one of the primary health centre under the particular health city.

PHASE 1: SCHOOLING OF BASIC HEALTH SCIENCES

This phase spanning for a period of about 2 years would school the future health professionals on the basic health sciences which would include the subjects like pharmacy, physiology, microbiology etc. At the end of the phase, screening tests can be seeked to segregate the students into the varied health professions based on their aptitude and core competencies. The main highlight of this program would be flexibility. The students should have full freedom to design their career and pull out and quit the health profession at their will. This phase can serve that purpose. This phase can also serve as a channel for the students of other professions who have strong passion to serve the community to join the medical fraternity. The another major breakthrough required during this phase is to inculcate the leadership qualities in the future health professionals. The health system is in utter need of eminent leaders who can guide and pull the health community into the track. Workshops and training sessions can help the students move forward on the key issues.

 

PHASE 2: PHASE OF CLINICAL TRAINING

The students who are selected after the completion of phase 1 by screening procedures will then undergo clinical training and learn the clinical curriculum. This phase will last for about 2 years for medical and nursing graduates and the period will vary with other health professions in accordance to the need. This phase of clinical training shall be conducted in each health city thereby training a set of graduates of each health professions namely primary care physicians, nurses, community health workers and other allied health professionals as per the need. This training would be under the single umbrella thereby promoting inter-professional relationships and helps in better understanding of the roles of the other health professions with obviously evident improved patient care and outcomes. If preferred the students can also be asked to undergo a 42 hour interactive inter-professional training workshop once in every academic year. This would help foster inter-professional relationships and encourage team work. The group of health professionals who undergo training in a particular health city shall be considered a "health team"

PHASE 3: PHASE OF CLINICAL INTERNSHIP WITHIN THE HEALTH CITIES

This is the most important phase in the training of the health professionals. In this phase the students shall undergo hands on training in providing the basic health care to the community. This phase shall last preferably for a period of about 1 and half years. During this phase the professionals shall receive experience on how to approach a patient as a team. The internship posting can be allotted in the different primary health centers under the same health city. Posting the students in both the urban and rural primary health centers will help the health professionals gains exposure on the varied health problems in a urban and rural setup.

~ Infrastructure and staffing recommendations:

 The health city shall be equipped with infrastructure and staffing pattern as per the standard government norms. Libraries, hostel facilities and well facilitated classrooms with e-learning facilities shall add to the glory.

• Addressing the key policy issues :

The "Health city" concept purports to solve the following key issues:

• The current health professions' education being centered around tertiary level of health care - The education of the health professionals at the health city level and providing training at he primary health centre level decentralizes this focus.
• The inequity in the distribution of health professions - The training of health professionals in rural PHCs shall help in drawing the health professionals to the rural and underserved areas.
• The shortage of health professions' manpower - As per the health city concept every health city shall train about 100 primary care physicians and nurses. Thus for a district of about 30 lakh population, a total of 1000 primary care physicians and nurses and other allied health professionals would evolve. This output is certainly high in comparison to the current graduation rates.
• Fragmentation of health care and lack of team based approach - The training of the varied health professions under the single umbrella of a Health City would help to inculcate the inter-professional coordination and responsibilities in the health professionals.
• Knowledge gaps:
• What is the solution to the migrating population of health professionals especially in a country with budget paucity?
• What is the average investment needed to establish a health city?
• Is there any changes that need to be incorporated into the health professions' curriculum?

 

CONCLUSION:

"Heal the world… And make it a better place" and so goes a famous number by Michael Jackson. Despite the many a thousand critics and controversies the health professions faces, it is the strong interest in the welfare and well being of others and the uncanny desire to provide relief to the people's sufferings that sets apart this noble profession. And now, its the time to fuel a growing movement to tackle the challenges facing the professional health workforce and contribute to a new era for health professions' education!

 

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