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

1. Accreditation of Public Health Courses in India: The Challenge Ahead DHANWANTARI ORATION B S GARG Prof & Head Dept. of Community Medicine MGIMS, Sewagram

2. 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”

3. According to the English dictionary, Accreditation implies: official recognition, general acceptance, assurance of quality.

4. Accreditation is required due to: A.Changing public expectations from doctors. B.Globalisation and international standards. C.Diversity in medical education. D.Moves towards international standards.

5. Changing public expectations of doctors: Mystique of medicine • Newspapers • Books • Radio • Television • Internet

6. “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.

7. B.Globalisation and international standards The world is shrinking: • Liberalization of economy • Telecommunications • More travels • Access to media • Cyberspace

8. The commission on macro-economics and health (WHO): Extra expenditure of $27 billion on health by the rich world in the poor world could save eight million lives a year – and boost the global economy. - BMJ, 5th Jan. 2002.

9. Social changes: • Education • Wealth • Innovations • Human rights • Concept of quality

10. International standards: • Aviation • Banking • Telecommunications • Environmental protection • Food safety • Human rights

11. International agreements (e.g., GATS 1994): • Global mobility • Common educational standards • Mutual recognition

12. 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.

13. C. Present diversity in medical education • Over 2,000 medical schools • Curriculum appear similar but contents? • Outcome of educational efforts?

14. 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.

15. UNITED 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

16. AUSTRALIA • 1985, Accreditation Committee of the Australian Medical Council (AMC) established. • Until then recommendations of GMC, U.K., were used.

17. LATIN 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.”

18. MALAYSIA • Attempts to develop an accreditation system based on USMLE.

19. CHINA • “Teacher centred” curriculum. • Very recently attempt to modernise medical education process. • Accreditation system for medical school programmes introduced.

20. 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

21. 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).

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

23. Standards must be: • Practical. • Recognise diversity. • Foster adequate development.

24. 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.

25. 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.

26. The standards are structured according to nine areas: • Mission and objectives. • Educational programme. • Assessment of students. • Students,. • Academic staff/faculty. • Educational resources. • Programme evaluation. • Governance and administration. • Continuous renewal.

27. Do Public Health Institutions Need Accreditation? Policy makers Health Managers Health professionals Needs based health system Academic institutions Communities 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.

28. THE INDIAN SCENARIO • 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.

29. 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 Indiashould address these concerns.

30. 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.

31. Purpose of 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”.

32. Framework for Accreditation • 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.

33. 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.

34. 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

35. 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.

36. The global conference on international collaboration on medical education & practices Illinois, USA in 1994 urges “that the priority concern be focused on the interface of health 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.”

37. MILESTONES IN THE DEVELOPMENT OF ACCREDITATION SYSTEM FOR PUBLIC HEALTH INSTITUTIONS IN INDIA Acceptance by Public Health Institutions, Professionals ? Effective Implementation strategy ? Regional Consultation at Chennai, 2002 Calcutta Declaration, 1999 Established systems in USA, UK, Canada, Australia Initiation of ROME in 1977 MCI Guidelines for Medical Education, including public health departments in medical colleges

38. 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”

39. Suggested Criteria for Accreditation • 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.

40. Suggested Criteria for Accreditation • 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.        

41. Suggested Criteria for Accreditation • 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.

42. Suggested Criteria for Accreditation • 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.

43. Suggested Criteria for Accreditation • 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.

44. Suggested Criteria for Accreditation • 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.

45. Suggested Criteria for Accreditation • 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

46. SOCIAL 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

47. The 48th World health Assembly in 1995 recognized that both medical practice and education need to be reoriented to achieve relevance, equity, cost-effectiveness and quality. • Social Accountability can be assessed by four • essential Reference points as fundamental • values for the health system development • Quality • Equity • Relevance • Cost effectiveness

48. Relevance Highest Quality Equity Lowest Highest Cost- effectiveness HEALTH COMPASS

49. 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.

50. VALUES DOMAINS Teaching Research Services Quality Equity Relevance Cost Effectiveness SOCIAL ACCOUNTABILITY GRID