REPORT OF THE MEDICAL EDUCATION REVIEW COMMITTEE

MINISTRY OF HEALTH AND FAMILY WELFARE GOVERNMENT OF INDIA

NEW DELHI 1983

CONTENTS Preface ………………… (iii) Acknowledgements ………………… (viii)

PART I Chapter I Introductory …………………………………………………………….……1-3 Chapter 11 Procedures relating to admissions to under-graduate courses………………………...4-6 Chapter III Procedures relating to admissions to the post-graduate course……………………….7-8 Chapter IV Duration of the under-graduate course and Internship………………………………..9-10 Chapter V Duration of the post-graduate courses and thesis……………………………………..11 Chapter VI Review of the Residency Scheme…………………………………………………. 12-13 Chapter VII Measures to bring about overall improvement in the under-graduate and post-graduate

education…………………………………………………………………………… 14-19 Chapter VIII Recommendations in regard to matters not covered by the Committee's terms of

reference……………………………………………………………………………. 20-22 Chapter IX Suggestions regarding the implementation of the Committee's recommendations….23-25 Chapter X Summary of recommendations …………………………………………………….26-29 Annexure I Copy of Ministry of Health & Family Welfare notification constituting the

Committee…………………………………………………………………………...31-32 Annexure II Details of meetings held by the Committee/Sub-Committees………….………………33 Annexure III Copy of Questionnaire issued by the Committee ………………………………… 34-36 Annexure IV Reports of previous Committees referred to by the Committee…………………….37 Annexure V An approach to the implementation of recommendations of the Committee………..38-42

PART II 1. Report of the Medical Education Review Committee—Part II ……………………………….43- 47 2. Report of the Sub-Committee on Medical and Para-Medical Manpower Requirements……... 48-54 APPENDICES I. Statement indicating details of the organisations addressed to secure information regarding Health Manpower, with the result thereof……………………………………………………………….55 - 56 II. Statement showing the number of unqualified Private Medical Practitioners as on 1-1-1982 (State-wise/System-wise) ……………………………………………………………………….57 Data in regard to admissions to MBBS course and Output of Graduate Doctors (1980-81)……58 - 64 Statement showing admissions/out-put in the Post-Graduate (Degree and Diploma ) and Post-doctoral courses in Allopathy (1980-81)………………………………………………………………….65 - 66 V. Available stock (as on 1-1-1982) of Health personnel under the various major National Health Programmes …………………………………………………………………………………….67 VI. Information regarding manpower data obtained from Central Public Sector Undertakings (as on 1-1-82) ………………………………………………………………………………………68 - 71 VII. Information regarding Hospitals/Dispensaries etc. maintained by Voluntary Health Organisations …………………………………………………………………………………..72 VIII. Existing stock of General Practitioners, Specialists, Dentists, Nurses and Pharmacists… 73 XI. Projection of demand of certain categories of Medical and Para-medical Manpower (including Tables1 to 12)………………………………………………………………………………. 74 - 92

PREFACE While inaugurating the first meeting of the Medical Education Review Committee Shri B. Shankaranand, Union Minister of Health and Family Welfare, had urged the Committee to evolve recommendations on its various terms of reference, ensuring that the same were in tune with the needs and priorities of the country and easy of speedy, practical implementation. He had urged the Committee to complete its work as early as possible. In view of the fact that certain information and analysis was available in the reports of similar committees established by the Government in the past, the Medical Education Review Committee did not consider it necessary to undertake visits to institutions in the country or to hold discussions outside Delhi. Instead, the Committee devised a questionnaire for eliciting the opinion of identified eminent specialists and teachers, located in various parts of the country. The Committee also had the benefit of informal discussions with the Chairman, University Grants Commission. Besides, it had the opportunity of hearing the views of the representatives of the All India Federation of the Junior Doctors' Associations. To ensure the maintenance of high standards of medical education it is necessary that existing teaching institutions strictly adhere to the regulations of the Medical Council of India in regard to admissions, faculty strength, availability of prescribed infrastructural facilities etc. While the basic emphasis should be to see that the existing institutions run on the most satisfactory basis, new medical colleges may be allowed to be established only after very careful examination of every proposal. Furthermore, a stricter view would require to be taken in regard to the continued recognition of institutions which have failed to maintain the requisite standards. While the Committee has evolved various recommendations for bringing about an improvement in the existing situation, it appears necessary that Government review and urgently bring about suitable amendments in the Indian Medical Council Act, 1956, to make it effective. In view of the need to bring about adequate coordination of efforts, on all fronts, as well as to lay the foundations of a well-considered, uniform approach towards all aspects of medical education it appears necessary for the Government to consider establishing a central authority to be responsible for coordination, planning and implementation of various medical and health education programmes, assessment of health manpower requirements and development programmes, provision of suitable financial support to medical and health institutions etc. The Committee has made certain recommendations in this regard and hopes that the Government would give due consideration to them. The only term of reference in regard to which the Committee has not so far finalised its recommendations relates to an assessment of the available stock of medical and para-medical health personnel and the projection of requirements for the future, keeping various related considerations in view. This task involves a great deal of time, specially as the basic information is not readily available. The Committee hopes to submit a further report, on this aspect, shortly, making such recommendations as may be possible, based on available information. I trust the Government would consider the recommendations of the Committee on an urgent basis, so that the much needed reform in the medical education system and related spheres is not avoidably delayed. The functioning of the Committee has been most competently handed by its Member-Secretary, Shri N. N. Vohra, who served it in addition to his heavy charge as a Joint Secretary in the Minis-try. He had to put in a great deal of hard work and harmonise discussions and varying views on

complicated issues. He has drafted the report of the Committee in very quick time, doing an excellent job. I would personally like to thank him. On my own behalf and on behalf of the Committee I would like to place on record our grateful thanks to Shri B. Shankaranand for his help and guidance and to the Ministry of Health and Family Welfare for sustained cooperation. DR. SHANTILAL J. MEHTA, Chairman September, 1982. New Delhi.

Medical Education Review Committee*

* The Committee was established vide Government of India Resolution dated the 8th September, 1981.

(v)

CHAIRMAN Dr. Shantilal J. Mehta MEMBERS Col. R. D. Ayyar Dr. I. D. Bajaj Dr. P. N. Chhutlani Dr. O. P. Gupta Dr. L. B. M. Joseph Dr. M. M. Mehta Prof. V. RamaHngaswami Dr. Rameshwar Sharma Dr. Y. P. Rudrappa Dr. B. N. Sinha Prof. H. D. Tandon Dr.K. N. Udupa Dr. P. N. Ward MEMBER-SECRETARY Shri N. N. Vohra STAFF OF THE COMMITTEE Shri R. Srinivasan, Research Officer. Shri J. C. Handa, Private Secretary to Chairman. Shri A. V. L. Narasinga Rao, Sr. P.A. to Member-Secretary. Shri Arun Kumar, Research Assistant (till May, 1982). Shri K. K. Mehta, Research Assistant (from July, 1982), Shri Sumit Chatterjee, Research Assistant. Shri M. S. Chawla, Stenographer. Shri S. C. Chitral, L. D. Clerk. Shri Jagdish Prashad, Messenger (till July 1982) Shri Kundan Singh, Messenger (from August 1982).

ACKNOWLEDGEMENTS The Committee wishes to place on record its grateful thanks to Smt. Madhuri Ben Shah, Chair-man, University Grants Commission, who kindly agreed to give us the benefit of her valuable views and experience, in informal discussions. Our thanks are also due to the eminent scientists and teachers (names given in Annexure HI) who took the trouble of favouring the Committee with their views, in response to the Questionnaire sent to them. We would also like to thank the representatives of the All India Federation of the Junior Doctors' Associations for acquainting the Committee with their views. Our thanks to various officers in the Ministry of Health and Family Welfare, the National Medical Library, and the WHO Programme Co-ordinator and Representative in India for supplying the Committee with publications, information and useful material. It would not have been possible for me to complete the work of the Committee without the extremely able and diligent support of Shri R. Srinivasan, Research Officer, and the sustained hard work of Shri J. C. Handa, P. S. to Chairman, Shri A. V. L. Narasinga Rao, my Sr. P. A. Shri Sumit Chatterjee and Arun Kumar, Research Assistants, M. S. Chawla, Stenographer and S. C. Chitral, L. D. C September, 1982. New Delhi. N. N. VOHRA, Member-Secy.

CHAPTER I INTRODUCTORY

The Ministry of Health and Family Welfare, Government of India, set up a Medical Education Review Committee vide Resolution No. U-12012|28|81-ME (Policy) dated the 8th September, 19812 consisting of the following:— 1.Dr. Shantilal J. Mehta, (formerly Director, Jaslok Hospital), Smdhula, N. Garnadia Road, Bombay-400026. Chairman 2. Dr. M, M. Mehta, Member of Parliament, 53, North Avenue New Delhi. Member 3. Dr B. N. Sinha, President, Medical Council of India, Kotla.Road, New Delhi. Member 4. Prof. V. Ramalingaswami, Director-General, Indian Council of Medical Research, New Delhi. Member 5. Dr. I. D. Bajaj, Director General of Health Services, New Delhi. Member 6. Prof. H. D. Tandon, Director, All India Institute of Medical Sciences, New Delhi. Member 7. Dr. L, B. M. Joseph, Director, Christian Medical College and Hospital, Vellore-632004. Member 8. Dr. O. P. Gupta, Director of Health, Medical Services and Medical Education,

2 Annexure

New Civil Hospital, Ahmedabad-380016. Member 9. Dr. Y. P. Rudrappa, (former Director of Medical Education and Research, Karnataka), Chairman, Post Graduate Medical Education Committee, Medical Council of India Ravidarshana 121, 10th Main, 6th Cross, Rajamahal Vilas Extension, Bangalore-560080. Member 10. Dr. Rameshwar Sharma, Principal, S. M. S. Medical College, Jaipur. Member 11. Dr. P. N. Wahi (former Director-General, ICMR), Executive Director Indian Association for the Advancement Medical Education, New Delhi. Member 12. Dr. P. N Chuttani (former Dean. Medical Faculty, Punjab University and former Director, Post-Graduated Institute of Medical Education and Research), 22, Sector 4 Chandigarh Member 13. Col/R. D. Ayyar (former Director-General of Health Services Govt of India) 27, Kalakshetra Colony Madras-600090. Member Dr. K. N. Udupa (former Director, Institute of Medical SciencesVaranasi), Professor Emeritus Banaras Hindu University., Varanasi (U.P.) 15. Shri N.N.Vohra, Ministry of Health and Family Welfare New Delhi Member- Secretary Secretary, Medical Council of India (Dr U B. Krishnan and latter Dr. P. S. Jain), was co-opted as a Member of the Committee. The terms of reference of the Committee are as follows:- (1) (i) to review the current admission procedures (including entrance tests) and domiciliary

restrictions for admissions to under-graduate and postgraduate courses and to make suitable recommendations separately, in regard thereto; (ii) to suggest measures aimed at bringing about overall improvement in the undergraduate and post-graduate medical education, paying due attention to (a) institutional goals; (b) content, relevance and quality of teaching and training and learning settings; and (c) evaluation systems and standards. (iii) to recommend the optimum duration of under-graduate and post-graduate cou-ses of study separately ; (iv) to examine the existing Internship programme and to recommend its future pattern; (v) to review the working of the Residency Scheme along with the Housemanship Programme and to make recommendations regarding a uniform pattern of post-graduate training. (vi) to examine the current requirement of Thesis or Dissertation as an essential part/ of post-graduate medical education and to make suitable recommendations in regard thereto; and (vii) to examine the feasibility of a period of service in the rural areas for medical graduates and post-graduates. (2) The Committee will also evolve realistic projections of medical manpower requirements (MBBS doctors, general specialists and super-specialists) during the Sixth Five Year Plan and beyond, taking into consideration: (a) the needs of Government based health care programme; (b) the requirement of doctors in the private sector; © the needs arising from bilateral agrees ments, international commitments and Technical cooperation among developing Countries; and necessity to redress regional imbalances in the distribution of medical manpower. (3) The Committee may also consider and make its recommendations in regard to any other related matter. The Union Minister for Health and Family Welfare, while inaugurating the first meeting the Committee, observed that the Committee may also take into consideration the recommendations of the various Committees set up in the past to consider similar and allied issues and make concrete recommendations to enable speedy consideration and decisions in regard thereto. He also emphasised the need on the recommendations being practical and easy of implementation, keeping all relevant factors in view. He reiterated the need of there being a uniform approach to medical education in institutions all over the country. The Minister urged the Committee to complete its work as early as may be possible. However, the report of the Committee relating to an assessment of medical manpower requirements may come later, as the effort involved in regard thereto would be time-consuming. The Committee commenced its work on 5th October 1981, when it held its first meeting. In all, the Committee held 9 meetings,* till the submission of this part Report. At its first meeting, the Committee decided to elicit the opinion of selected Deans and Principals

of medical colleges and identified eminent medical scientists on some of the specific issues arising out of its terms of reference. Accordingly, a Questionnaire**was evolved and sent out to 62 experts all over the country, of whom 41 (i.e. 66.12 percent) responded. The Committee also invited Dr. (Mrs.) Madhuri Ben Shah, Chairman, University Grants Commission and representatives of the All India Federation of the Junior Doctors' Associations to hear their views on various issues before the Committee. The Committee also undertook a rapid review of the views and recommendations of the Committee*** appointed in earlier years. As regards the assessment of medical manpower requirements and projection of future needs, the Committee appointed a Sub -Committee, consisting of the following to evolve suitable recommendations:— 1. Dr. O. P. Gupta, Director of Health, Medical Services and Medical Education, New Civil Hospital, Ahmedabad (Gujarat) 2. Dr. Rameshwar Sharma, Principal, S.M.S. Medical College, Jaipur. 3. Dr. H. D. Tandon,Director, All India Institute of Medical Sciences, New Delhi 4. Dr. K. Ramachandran, Associate Professor and Head, Biostatistics Unit, All India Institute of Medical Sciences, New Delhi. 5. Dr. U. B. Krishnan, Secretary, Medical Council of India, Temple Lane, Kotla Road, New Delhi (uptill 30-4-82). Dr. P. S. Jain, Secretary, Medical Council of India, Temple Lane, Kotla Road, New Delhi (from 1-5-82 to date). 6. Shri M. C. Verma Joint Advisor, Manpower Unit, Planning Commission, New Delhi 7. Prof. Usha K. Luthra, Senior Deputy Director General, Indian Council of Medical Research, Ansari Nagar, New Delhi.

8. Prof. Gautam Mathur, Director, Institute of Applied Manpower Research, Indraprastha Estate, New Delhi. 9. Dr. P. C. Bhatla, Dean, IMA College of General Practitioners, New Delhi. 10. Shri N. N. Vohra, Joint Secretary, Ministry of Health and Family Welfare, New Delhi. Convenor 1.8 As the assessment of medical and paramedical manpower requirements involved a great deal of time the Committee decided to submit a part report on its other terms of reference. 1.9 As various Committees established in the past had gone into the requirements of a need based medical education programme, the Committee did not consider it necessary to present a voluminous report, reiterating the historical aspects etc. of the existing pattern. To enable speedy action by the Government, the Committee also decided to make suggestions for the effective implementation of its recommendations

CHAPTER II PROCEDURES RELATING TO ADMISSIONS TO THE UNDER GRADUATE COURSE Eligibility criteria for admissions 2. The Committee is of the view that there is no need for any modification in the Regulations of the Medical Council of India, which set out the following criteria for adjudging the eligibility of candidates for admission to the M.B.B.S. course: “No candidate shall be allowed to be admitted to the Medical Curriculum proper until (i) he has completed the age of 17 years at the time of admission or will complete the age on or before 31st December the year of his admission to the 1st M.B.B.S. course. (ii) he has passed : (a) The Higher Secondary Examination of the Indian School Certificate Examination which is equivalent to 10+2 Higher Secondary. Examination after a period of 12 years study the last two years of study comprising of Physics, Chemistry. Biology and Mathematics or any other elective subjects with Engish at a level not less than the Core course for English as prescribed by the National Council for Educational Research and Training after the introduction of the 10+2+3 years educational structure as recommended by the National Committee on Education. Note—Where the course content is not as prescribed for 10+2 education structure of the National Committee, the candidates will have to undergo a period of one year pre-professional training before admission to the medical colleges. (b) the Inter medical examination in Science of an Indian University Board or other recognised examining body with Physics, Chemistry and Biology which shall include a practical test in these subjects. OR (c) the pre-professional pre-medical examination with Physics, Chemistry and Biology after passing either the Higher Secondary School examination, or the pre-university or an equivalent examination. The Pre-professional pre-medical examination shall include a practical test in these subjects. OR (d) the first year of the three years degree course or a recognised University, including a practical test in these subjects provided the examination is a "University Examination". OR: (e) B. Sc. examination of an Indian University, provided that he has passed the B. Sc examination with not less than two of the following subjects - Physics, Chemistry, Biology (Botany, Zoology), and further that he has passed the earlier qualifying examination with the following subjects – Physics, Chemistry, Biology and English.

OR (f) any other examination which, in scope and standard is found to be equivalent to the Intermediate Science examination of an Indian University|Board, taking Physics, Chemistry and Biology including a practical test in each of these subjects and English. Note (a) The pre-medical course may be conducted either at a Medical College or a Science College. (b) After the 10+2 course is introduced, the integrated courses should be abolished. Method of Selection 2.1 The Committee considered the existing Regulations of the Medical Council of India in regard to the selection of students to medical colleges and is of the opinion that a National entrance Examination, which should be exclusively of an objective type, for admission to the MBBS course in all the medical colleges in the country would be an ideal arrangement, to put an end to the varying admission standards. Candidates taking this examination could, offer their preferences in regard to the institutions they would like to be admitted to, anywhere in the country. The result of the examinations could be so complied as to set out the inter-se merit of the candidates while keeping their choices in view. This matching system would ensure admissions on merit, adjudged on a countrywide basis, and also, provide all round satisfaction. This would also ensure against the avoidable cost and inconvenience caused to the students in their having to sit for a number of admission tests, held on various dates, at different stations. However, as the establishment of the National Entrance Examination would naturally lake some time in view of the preparatory work involved, the Committee is of the view that for the time being the phased approach mentioned below may be adopted :— (a) All admissions to the MBBS course in medical institutions under the control of the Central Government and the Union Territory Administrations should be through a common Entrance Examination (b) Admissions to the MBBS course in all the medical colleges including privately run institutions, located in a State should be through a common Entrance Examination to be organised by the State Government in consultation with the University (ies) concerned. 2.1.1 The Committee strongly condemns the charging of capitation fees by some medical colleges from students seeking admission to the MBBS-PG courses and recommends that the Government should take the most urgent steps, including legal measures, if necessary; to put an end to this un-wholesome, practice. 2.1.2 At present the various Higher Secondary Examination Boards|Universities conduct School Leaving|Higher Secondary| Pre-medical| Intermediate etc. examinations on different dates. Consequently, the results of these examinations are announced on varying dates, in the context of its recommendation in para 2.1, the Committee observes that it would be necessary for the various examining bodies to hold the feeder channel examinations within a re-organised time schedule so that the results of the various examinations are available before the last date of application for admission to the National Entrance Examination. Till such time as the arrangement proposed above- can be secured, the non-declaration of results of any of the feeder-channel examinations should not stand in the way of the interested students sitting for the National Entrance Examination. Candidates who qualify in the said examination, may be required to produce the requisite certificates of their having passed the prescribed basic eligibility exa-mination, before their results are declared.

2.1:3 As regards the central agency which would hold the National Entrance Examination, the Committee is of the view that the Government may select a suitable autonomous institution, existing or to be created, which possesses the requisite expertise. 2.1.4 In so far as the setting of papers for the National Entrance Examination is concerned, the Committee recommends that while there should be a test in Physics, Chemistry, Biologv and General Knowledge, the language of the examination should be English as, for many years to come, the teaching of medicine, at all levels, would continue to be in English. 2.1.5 It was brought to the notice of the Committee that some of the medical institutions which admit candidates to entrance tests for the MBBS course issue notices, informing the candidates about their admission to the entrance examination, only a few days before the test. Due to despatch and postal delays, these notices are in a large number of cases, received by the candidates either just before the date of the examination or even after the examination has commenced, thereby depriving candidates who reside at distant places of the opportunity of competing for admission. The Committee is therefore, of the view that intimation to candidates about their admission to examination should be sent-to them well in time to enable them to make timely travel and other arrangements. Further, existing examinations as well as the proposed National Entrance Examination should be held, every year, on specified dates. Reservation of seats 2.2 In addition to the prescribed percentage of reservation of seats for SC and ST candidates, the various States|UTs with medical colleges have been making reservation for a variety of other categories on an apparently ad hoc basis. In some States the reservations are as high as 68 per cent of the total number of seats for admission to the undergraduate course. 2.2.1 The Health Survey and Planning Committee 1961 had recommended that except for SC and ST candidates there should not be any other reservation and that merit should be the only basis for admissions. After consideration, the Committee recommends the approach stated below:— (a) The State Governments may be permitted to fix percentage-wise reservations for SC |ST candidates as may be prescribed by the Central Government, the same being related to the SC and ST population in the State; (b) Any reservation over and above that in (a) above, for other categories of beneficiaries, should be done only after procuring the prior sanction of the Medical Council of India; (c) The aggregate of various categories of reservations, including SC|ST, should not exceed 33 per cent of the total number of seats available in each college; There should be no further relaxation of the existing M.C.I prescription requiring SC|ST candidates to possess at-least 40 percent marks (against 50 percent for general category candidates) in English | General Knowledge, Physics, Chemistry and Biology, taken together, at the entrance examination for admission to the medical course; There should be no carry forward of reserved seats of any category, from one year to the next. All seats reserved for SC|ST candidates which remain unfilled may be utilised by admitting eligible SCI ST candidates from neighbouring States|UTs. If unabsorbed SC|ST candidates from other States |UTs are not available in the requisite number, the vacant seats should be thrown open to the general category candidates. The Government of India would have to establish a suitable mechanism to operate the above recommended approach;

(f) With a view to providing effective protection to the SC | ST candidates, the existing Medical Council of India prescription regarding the establishment of special coacning facilities should be enforced most vigorously. Such coaching should be arranged for SCJST candidates who intend to appear for the entrance examination. Also special counselling arrangements should be made for the SC|ST students admitted to the MBBS course. Domiciliary restrictions 2.3 The Committee noted that except in a handful of Central institutions, candidates can seek admission only to medical colleges located in the State| UT to which they belong. The Medical Education Committee (1969) and the Medical Education Conference (1970) had recommended that 5 percent of the total number of seats in every medical college may be reserved for candidates from otherStates. It was also recommended that such reservation of seats should be on reciprocal basis. Taking into account all relevant considerations, the Committee recommends that the final objective should be to ensure that all admissions to the MBBS course should be open to candidates, on an all India basis, without the imposition of existing domiciliary condition. However, to begin with, not less than 25 percent of the seats in each institution may be open to candidates on all-India basis. This would pose no practical problems in view of the Committee's recommendation, made earlier, to establish the National Entrance Examination. A suitable percentage of these open seats may be made available to the students from the backward areas in the States | UTs, particularly those without any medical college. The Government of India may fix a date, taking various relevant consideration into view by which the alternate to objective of all seats being open to admission on all India basis would be achieved. Junior Doctors' Federation's views on reservations 2.4 The representatives of all India Federation of the Junior Doctors' Associations made a very strong plea before the Committee that economic criteria may be applied to the reservation of seats for the SC|ST so that the candidates belonging to well-to-do families do not enjoy protection. Government may like to examine this view. The Committee is not competent to make any comments, not being fully seized of the implications of the suggestion in other sectors of functioning.

CHAPTER III PROCEDURES RELATING TO ADMISSIONS TO THE POST-GRADUATE COURSES

Eligibility criteria for admission 3. The Committee recommends that for admissions to the various post-graduate courses (Diploma, Degree and post-Doctoral) the candidates should have obtained full registration with the Medical Council of India after passing the final MBBS examination and should have qualified in the entrance examination referred to in para 3.1 below. Method of Selection 3.1 The Committee considered the possibility of holding an all India Entrance Examination for admissions to the post-graduate courses in the various medical institutions. It is of the firm view that this would the only viable approach towards the establishment of uniform admission standards. Such an examination, which may be called the National Entrance Examination for Post-Graduate Courses, should provide for tests in General Knowledge of Medical subjects besides a battery of well constructed tests to assess aptitude and competence and to procure a complete profile of the candidate. The tests should comprise objective type questions. The Central Government may, keeping all relevant aspects in view, identify the authority|agency, which may hold this examination. It would be advantageous if the selected agency is an autono-mous body. The candidates should be selected strictly on the basis of merit, emerging from the result of the proposed, examination. 3.1.1 The approach set out in para 2.1 would mutatis mutandis; apply in the case of the proposed National Entrance Examination for admission to the Post-Graduate courses. Reservation of seats | domiciliary restrictions 3.2 The Committee is of the opinion that there should be no reservations for admissions to the various post-graduate courses, and merit in the proposed National Entrance Examination should be the only basis. However, one Member of the Committee was of the considered view that the constitutional provisions in the matter should also be enforced in the case of admission to Post-graduate courses. The Committee also recommends that all admissions to the Post-graduate courses, in any institution, should be open to candidates on an all India basis and there should be no restriction regarding domicile in the State|UT in which the institution is located. 3.2.1 As regards SC|ST candidates, the Committee is of the view that such of them who have passed the MBBS examination and gained full registration may be enabled to secure admissions to higher courses by providing them with special coaching |counselling facilities. Arrangements for this should be made by the State and U.T. Governments in consultation with the local university (ies) and the Deans'Principals of the concerned medical institutions. Needless to say, such special facilities would be required to assist such SC|ST candidates who are not likely to secure admissions, on merit basis, through the National Entrance Examination. Rural Service 3.3 The oft-repeated suggestion from various quarters, that compulsory rural service for a pres-cribed period should be a pre-requisite for admission to post-graduate courses was considered by the Committee. The overwhelming opinion of the Deans|Principals and other medical scientists whose views were elicited by the Committee, is that it would not be a practical proposition. The Committee feels that as the Government may not be in a position to provide employment in the

rural areas to all the medical graduates who aspire to seek higher education it would be impracticable to impose the condition of compulsory rural service. However, the Committee took note of the fact that as the graduates who have actually served in the rural areas would have had no time or opportunity to prepare for and take the proposed Entrance Examination, suitable weightage, say 10 per cent additional credit in the overall assessment at the Entrance Examination for Post-graduate Courses should be afforded to the applicants who have served in the rural areas for atleast two years. The specific additional credit weightage to be afforded to such candidates, qualifying in the Entrance Examination, may be worked out by the Government through a group of experts. 3.4 The Committee considered the question of enabling doctors in government service to obtain post-graduate qualifications, as they may not be able to compete with fresh graduates at the Na-tional Entrance Examination. The Committee feels that the needs of the situation without be met if in-service personnel are provided with the opportunity of undergoing training in identified subject specialities, the duration of each course being related to the training objectives. Doctors who are thus trained could take NBE|NAMS examinations for securing higher qualifications, consequent to undergoing periods of practical training at selected centres. However, if any in-service candidates opt for post-graduate qualification tlirough regular courses, suitable credit, say 5 percent may be awarded to them while computing the results of the National Entrance Examination.

CHAPTER IV DURATION OF THE UNDER-GRADUATE COURSE AND INTERNSHIP

Duration of the MBBS Course 4. The Committee reviewed the usefulness of reviving the erstwhile Licentiate Course or intro-ducing a new short term course in view of the reluctance of the medical graduates to serve in the rural and backward areas. In tins context the Committee after taking into account the recom-mendations of the various Committees set up in the past, is of the view that there should be only the fact whether the doctors are required to serve in the rural or the urban areas, the poor or the rich, whether they are required for hospital based curative services or for community oriented, preventive and promotive health care (services. The Shrivastava Committee3 had noted that there was no basis for suggesting the re-introduction of the Diploma or Licentiate Course only for meeting the needs of the rural areas. The, Committee is of the view that the resolution of the health problems of the country require better and more relevantly trained doctors rather than less trained ones. It was observed that in view of the large number of medical graduates being presently produced in the country, the real problem is to enable the doctors to work in rural areast, urban slums etc., and not to create a fresh stream of semi-qualified professionals who may also, as recent experiences show, like to settle and work in the urban developed areas. The Committee is accordingly of the view that there is basis for either1 starting an intermediate course or reducing the existing duration of the MBBS Course. 4.1 The period of 4-1/2 years for academic study and a one year Internship may continue, as at present. This period of 4-1/2 years should be divided as under :— Phase I ... Pre-clinical . . . 1-1/2 year Phase II ... Para--clinical .. 3 years Phase III. ... Clinical 3 years The above training schedule is as per the existing regulations of the M.C.I, currently followed by medical colleges all over the country. Internship 4.2 The majority response to the Questionnaire /circulated by the Committee is in favour of continuation of the existing one year Internship after 4-1/2 years of academic learning. The Committee is of the view that the prescription of one year Internship is an essential feature of the educational programme which cannot be diluted or tempered with. The Internship period should have a well structured content. The Committee is of the opinion that rural Internship for atleast a period of six months is necessary. However, taking note of the fact that the requisite infrastructural facilities required for the imparting of Internship training on an effective basis have not yet been provided in the rural training centres by a number of medical colleges it recommends that six months of the total Internship period should be spent in accredited districts|taluk hospitals and rural health centres. The responsibility for providing such training must rest entirely on the medical colleges and the State Governments. The Committee re-commends that the Rural Training Centres at which the Interns are to be posted should be managed, in all respects, by the medical colleges. The Medical Council of India should take effective steps to see that these facilities are provided by the medical colleges and if this is not done within a reasonable period, to be stipulated by the Central Government |MCI, action should be taken by the Council to de-recognise the defaulting institutions. The Central Govt should require the MCI to submit regular reports to the Government regarding the colleges which have 3 Group on medical Education and Support Manpower 1975

so far not taken adequate action to implement the rural Internship programme. It was observed that the Council has so far not taken any action against the defaulting institutions nor submitted regular reports in the matter to the Government. 4.2.1 During the period of the six months non-rural Internship, the students should work in the teaching hospitals, 4 months of which would comprise rotating Internship with a structured content and 2 months for training in the subject-speciality of the student's choice, as an elective assignment. During tins period the students should be designated as Junior Housemen and be responsible for all aspects of patient care, under the effective supervision of senior and experienced Consultants working in these hospitals. Within the aforesaid approach it would be necessary to remove the existing condition that candidates seeking admission to a postgraduate course may do so only in the subject speciality in which they have done Houseman-ship for a prescribed period. This stipulation is not rational and merely creates a variety of available problems. 4.2.2 The Committee hopes that, in due course, the Interns would be able to do their full Internship period outside the college hospital to gain substantial practical experience. At the conclusion of the Internship period, there should be a formal in-house clinical examination in the various disciplines to assess the work done and practical experienced gained by the trainees. High weightage should be afforded to such an evaluation, within the overall performance schedule. The Committee is of the view that unless a student has cleared this examination, he should not be entitled to the grant of the Degree. If he fails the Internship period may be extended by such period as may be necessary, after which he would again be required to take the examination. The Committee noted with concern that senior faculty members in the medical colleges do not take the required interest in supervising the work of the Interns during the lattefs rural training. No matter what changes are recommended to be brought about in the pattern of Internship they would have little meaning if the Professors|Senior Teachers do not personally instruct (supervise the students during this crucial period of their training. The Committee strongly recommends that Professors and senior faculty members in the colleges should be deputed to the PHCs |District Hospitals|Taluk hospitals etc. to supervise the training of the students during their Internship period. The Committee took note of the reported cases relating to the harassment of Interns by the local unregistered and unqualified medical practitioners operating in the rural areas. The Committee is of the view that the State Governments|U.T. Administrations should provide suitable security and such legal protection as necessary to the Interms and young doctors posted in the field.

CHAPTER V DURATION OF POST GRADUATE COURSES AND THESIS Duration 5. The Committee reviewed the existing system of admissions to the various post-graduate courses, as per the provisions in the recommendations of the Medical Council of India, viz., 2 years for post-graduate Degree courses and one year for Diploma courses, both after one year of House-manship. In view of the recommendation of the Committee that under-graduate students should be involved, during their Internship, in effective clinical training at the Districtj Taluk level hospitals and in the designated centres in the rural areas, it is of the further view that after obtaining the Degree, doctors may become eligible for seeking admission to a post-graduate course straightway, after full registration with the M.C.I. In other words, there should be no need for the candidate having to compulsorily go through a period of Housemanship. In this context, the Committee is of the view that the duration of the post-graduate degree course should be three years and the duration of the Diploma course should be two years after full registration. The Committee is of the view that this will provide flexibility for the evolution of relevant training programmes and provision for suitable training in the related subjects. The number of Resident seats should be specifically earmarked, department-wise, the number thereof being related to the employment opportunities and assessed requirements based on actual service loads. The number of seats, in each post-graduate department should be fixed with the prior approval of the Medical Council of India. The Council should decide the number of Resident seats, department-wise, with reference to the assessed medical manpower requirements. Thesis 5.1 The Committee considered, in some depth, the pros and cons of continuing to have Thesis as a compulsory requirement for qualifying in the post-graduate examinations. 37 out of the 41 experts who responded to the Questionnaire sent by the Committee are in favour of retaining the requirement of thesis. The Committee was generally convinced of the value of Thesis in view of the fact that it contributes to the development of the spirit of the inquiry, besides exposing the students to the*techniques of research, critical analysis, acquaintance with the latest advances in medical sciences and the manner of identifying and consulting available literature, preparing papers for presentation: at Conferences etc. At the same time, the Committee is concerned at the manner in which the whole system of Thesis is being actually implemented at present and how much it falls short of the expectations of having it as a compulsory requirement. The Committee is of the opinion that Thesis should be compulsory for non-clinical subjects while being optional for clinical subjects. In the latter case, where a student has opted for Thesis, extra credit| preference should be given in his future career prospects. The effectiveness and success of this approach could be reviewed at suitable intervals. The M.C.I, should undertake speciality-wise review in the light of the above recommendation and modify their Regulations accordingly. 5.2 The M.C.I, would also have to ensure that teachers take adequate interest in the identification of relevant subjects and provide effective guidance to the students in this regard.

CHAPTER VI REVIEW OF THE RESIDENCY SCHEME

6. The Committee reviewed the working of the Residency Scheme specially keeping in view the oft-repeated grievances of the Resident doctor’s and the decisions taken from time to time by the government in regard thereto

6.1 According to the existing M.C.I. Regulations, applicants for post-graduate training should have obiained full registration and, subsequently lone Housemanship for a period of one year prior to seeking admission to a post-graduate Degree| diploma Course. The period of training for MD|MS is three years after full registration, including one year of Housemanship or equivalent there if and for Diploma courses it is two years after full registration, including one year of Housemanship. These are the minimum requirements and the universities and medical institutions are therefore, not prevented from prescribing a longer period of training. The in-service training requires the trainee to be resident in the campus so that he can be given graded responsibility in the management and treatment of patient's entrusted to his care. As regards post-doctoral degrees, the period of training is two years for those who already possess a Post-graduate course. The M.C.I, have also recommended that the Post-graduate training could be delinked from Housemanship

6.2 Post-graduate and post-doctoral students, designated as Junior Residents and Senior Residents, have been agitating, in recent years, for improvements in their working conditions, remunerations, etc. which vary from State to State. In 1974, the Government of India appointed Committee under the chairmanship of Shri Kartar Singh, i.e. then Additional Secretary in the Ministry of Health and Family Welfare, to consider the demands of the "junior doctors", which includes both junior and senior Resident doctors in the government run hospitals in Delhi. On the recommendations of the Kartar Singh Committee, certain benefits were extended to the junior doctors appointed in the Central Government hospitals all over the country. During the last few years, their service conditions have been improved further. The Committee noted that Government have extended the following benefits to the resident doctors :-

(i) the break(s) from the date of completion of the senior residency to the date of appointment in Government service will be condoned for the purpose of granting retirement benefits; (ii) all inclusive leave is allowed at the rate of 24 days during the first year and 30 days during the second and third years, to the Junior Residents; (iii) the residents will not be required to do any laboratory investigations, except those which the Head of the Department or the residents themselves consider necessary; (iv) a sum of Rs. 250 is paid to the student for writing Thesis; (v) all unmarried Junior Residents would be allotted free of charge, one-room accommodation and married and senior residents would be provided with two-room accommodation. Till this is done, House Rent Allowance at prevailing Government rates would be granted to the Residents; (vi) while the Junior Residents receive stipends at varying rates from First to Third year the Senior Residents are placed in the pay scale of Rs. 650-30-710 plus usual allowances against tenure-posts for 3 years and are governed by the Central Civil Services (Temporary Service) Rules, 1965. They are also entitled to P.G. allowance of Rs. 50 per month if they hold a P.G. Diploma and Rs. 100 per month if they hold a P.G. degree. They are also entitled to NPA @ Rs. 150 per month and (vii) the continuous active duty for Residents should not normally exceed 12 hours at a time; they are also required to be on call duty for periods not exceeding 12 hours at a time, subject to exigencies of work. They are allowed one weekly holiday, by rotation.

6.3 The Committee reviewed the demands submitted by the All India Federation of the Junior

Doctors Associations. After hearing the representatives of the Federation and keeping in view the fact that the doctors seek, admission to the Residency Programme in order to gain higher quali-fications, the Committee makes the following recommendations :-

(a) The admissions to the various P.G. Courses (Degree and Diploma) should be directly related to service loads, manpower requirements of specialists and the clinical facilities available. In this context, the Committee recommends the demand of Resident Doctors to constitute a National Health Service, particularly keeping in view the commitment of Government to provide Health for all by 2000 A.D. Consequently, the number of vacancies of junior|senior Residents in each subject speciality would require to be related to the assessed manpower requirements. (b) The leave benefits already agreed to by the Government and referred to in para 6.2(ii) are adequate, considering the training requirements of Resident doctors. (c)Labour laws cannot be applied to Resident doctors undergoing training for securing higher qualifications. They are undergoing in-service training and are not on jobs in which the training and the service components can be separated. As such there can be no justification for fixing the limits, on a policy or legal basis of the hours of work required to be put in, per week. (d) The period of Junior Residency cannot be treated as regular service till such time as the number of seats in the various post-graduate courses are related to the manpower requirements and actual employment opportunities. Once this is done there should be no difficulty in treating the entire period of training for award of service benefits. (e) The period of service of Senior Residents may be treated as Government service for the purpose of service benefits like pension, gratuity, etc., provided that the incumbents seek and secure regular employment in Government. Consequently, the breaks, if any, between the date of completion of training|securing of post-doctoral degree and the date of entry into Government service may be condoned as per Government Rules. (f)There should be no upper age limit for admission to the Senior Residency Programme. In regard to entry into Government service, the maximum age limit should be raised by suitably amending the relevant recruitment rules so that doctors with Post-graduate|Post-doctoral degrees can enter Government service without having to specially seek relaxation of age limits presently prescribed. (g) In the case of non-clinical departments since candidates with post-graduate qualifications are not readily available. Demonstrators |Tutors may be appointed against the posts of Junior Residents and their services may be continued against regular vacancies, so that the shortage of staff in these specialities could be suitably met without any further loss of time. Such Demonstrators|tutors may be allowed to enrol themselves for P.G. qualifications while working in the departments. After securing P.G. qualifications they may be appointed as Lecturers without having to go through a fresh process of selection, other things being equal. (h) The Committee recommends that the Residents should also undertake various laboratory investigations, as part of their training. In this respect the Committee does not agree with the Government decision at Para 6.2(iii).

6.4 The Committee is of the opinion that after post-graduation there is no need for the clinical specialists to put in 3 years of further service as Senior Residents or Registrars, etc., to become eligible for appointments in Government service. Accordingly, the Committee recommends that the recruitment rules for appointments to the posts of Lecturers and Assistant Professors should be suitably amended.

CHAPTER VII MEASURES TO BRING ABOUT OVERALL IMPROVEMENT IN THE UNDER-

GRADUATE AND POST-GRADUATE EDUCATION

7. One of the terms of reference of the Committee is "to suggest measures aimed at bringing about overall improvement in the under-graduate and post-graduate medical education, paying due attention to :— (a) institutional goals; (b) content, relevance and quality of teaching and training and learning setting ; and (c) evaluation systems and standards."

The Committee considered the recommendations of the MCI on under-graduate medical education, adopted by the Council at its meeting held on 19-3-1981. The Committee also took note of the recommendations made by the Committees, set up from time to time, to review post-graduate medical education in regard to the institutional goals, curricular contents, etc. While broadly agreeing with the approach of these various Committees, the Committee, in the light of the mandate given to it, wishes to draw attention in this Chapter to some of the essential features of under-graduate and post-graduate medical education which should act as guidelines to the formulation of institutional goals, course content, evaluation methods, etc. The Committee further believes that while institutional goals should be considered separately for under-graduate and post-graduate medical education; there is considerable commonality between the two in so far as educational technologies, teaching and learning situations and evaluation systems are concerned. Indeed, there is a continuity between under-graduate and post-graduate medical education.

Basically, in spite of difference in the process of medical education at under-graduate and post-graduate levels, the ultimate purpose is to train physicians to fit into different levels of the health care system and to be able to resolve the health care problems of the community. Viewed from this angle, it could be said that the ultimate goal of medical education, be it under-graduate or postgraduate, is that it enables its products to deal, in the most effective manner, with the health problems of the society.

7.3 In this Chapter, the Committee, in the first instance, separately considers institutional goals for under-graduate and post-graduate medical education and then goes on to collectively consider, for both under-graduate and post-graduate education, the other aspects under the term of reference quoted in Para 7.

Institutional Goals for the Under-graduate Medical Course

7.4 The broad objective of under-graduate medical education is to produce medical graduates who would have the capability of providing comprehensive health care to both rural and urban communities. Such care should not only be curative but also include preventive and promotive aspects of health as well as rehabilitative services in an integrated manner.

7.4.1 In order to be able to do so, the student should have adequate understanding of :— (a) the structure, functions and development of the human body, including immuno-defence mechanisms, factors which disturb them and the mechanisms and forms of disorders which may result therefrom as relevant to the understanding of the clinical manifestations of diseases commonly prevelent in the community;

(b) methods of first level handling, promptly and efficiently, common, acute emergencies: (c) techniques of management of health problems including drag therapy, and should also be able to select the most appropriate form for a given patient, with due consideration to its cost effectiveness; (d) legal and ethical implications of medical care; (e) local patterns of diseases, environmental pollutions, occupational health hazards, communicable diseases, family welfare programmes, material and child health and nutrition ; (f) special problems of vulnerable sections of the rural and urban community including the care of mother and child and (g) the basis of human behaviour and role of psychological factors both in health and disease. 7.4.2 After successfully going through the prescribed course of learning and training, the young doctor should be capable of :— (a) diagnosing common disorders with the help of such diagnostic facilities as are likely to be available/expected in the average community settings; (b) performing simple laboratory tests and operative procedures, including surgical methods of fertility control;providing counselling and appropriate measures of management when drugs and other medical measures are not necessary; © providing advice about prevention of disease and promotion of positive health; and (d) establishing good working relationship with his medical colleagues and members of allied health professions.

7.4.3 The doctor should recognise the limitations of his knowledge and abilities and seek help when necessary. He should be an independent learner-with attitudes to self-evaluation and self-education. This will promote continuing improvement and adaptation to changes in medical practice, whether these result from the changing needs of the community or from the advances in the medical sciences.

Institutional goals for Post-graduate Courses 7.5 The Committee feels that the institutional goals for both clinical and non-clinical subjects in the post-graduate courses are more or less similar. However in view of the variations in the practice field to which post-graduate doctors are ultimately exposed, the Committee spells out, seperately, the institutional goals for clinical and non-clinical medical courses.

Clinical Specialities 7.5.1 The educational and training programme leading to the award of the post-graduate degree in clinical subjects is aimed at imparting knowledge, abilities and skills to enable the trainee to eventually services a specialist|teacher| research worker in the field of his speciality.

(1) The trainee should possess adequate knowledge pertaining to his speciality in respect of:— (a) applied structure and functions of the human body and patho-physiological mechanisms determining the clinical course and evaluation of disease; (b) important national health programmes and local pattern of commonly prevalent diseases ; (c )latest modalities of therapy ; (d) simple methods of statistical analysis of data ; and (e)developing frontiers of knowledge.

(2) On the successful completion of the learning and training course, the specialist should be able to :- (a) manage effectively all clinical problems and handle emergencies independently ; (b) make a rational plan of investigations and management of a given case ;

© perform common laboratory tests: understand the principles of essential laboratory tests and clinical procedures and interpret laboratory data for the diagnosis and management of cases ; (d) know his limitations and those of the facilities available as also when to refer patients that need more specialised care; (e) make use of the library to collect the relevant information ; and (f) identify a research problem, plan a rational scheme for its solution, make a critical analysis of the data and interpret them in ,the light of the contemporary knowledge.

(3) A post-graduate should be able to plan course of study for the students, defining the objectives; be capable of participating in didactic and tutorial teaching and be familiar with educational techniques which make learning efficient and effective.

Non Clinical Specialities 7.5.2 The educational and training programmes leading to the award of the post-graduate degree in non-clinical subjects are aimed at imparting knowledge, abilities and skills to enable the trainee to eventually serve as an independent investigator, researcher and/or teacher in his speciality. In order that he may attain this goal, he should :— (1) possess current knowledge relating to all fields pertaining to his speciality and be familiar with the developing frontiers of knowledge ; (2) be able to identify a research problem pertaining to his speciality, plan .a rational scheme for its solution and after carrying it out make a critical analysis of the data and interpret it in the light of contemporary knowledge. (3) be able to prepare a research protocol, succinctly defining objects of study, lacunae in existing knowledge and outline rational steps to achieve the objects, providing critical review of existing knowledge in literature ; (4) be able to select and apply the most relevant statistical method for analysing research data, pertaining to a given problem . (5) be able to make use of the library to collect relevant information ; (6) be familiar with the principles of the working of different types of equipment essential to his research work and for teaching students; and (7) be able to plan a course of study for the students defining the objectives; be able to participate in didactic, tutorial and laboratory teaching exercises and be familiar with educational techniques which make learning efficient and effective. Curriculum of Under-graduate Medical Education 7.6 In translating the institutional goals, enumerated in Para 7.4, into a curriculum, it is essential, to bear in mind that it has to be a dynamic one. As the problems related to health change with shifts in the socio-economic and other factors, medical education must also be adapted continuously to prepare the students to meet the changing needs of the society. 7.6.1 A reference has been made earlier to the recommendations of the MCI in regard to the curri-culum on under-graduate medical education. The Committee wishes to emphasise the importance of certain areas, mentioned here under, in the development of the curriculum. 7.6.2 There is mounting criticism that the present under-graduate medical education process does not pay sufficient attention to practical skills and competence involved in the delivery of primary health care. The Committee wishes to emphasise that the curriculum should provide opportunities for an education that is problem-solving and competence-building backed, to the extent needed, by theoretical knowledge. This cannot be achieved by the efforts of a single faculty member or a department but must be the total faculty commitment of the entire institution.

7.6.3 The Committee agrees with the recommendations of the MCI that students should be posted; in a general practice out-patient unit for a period of one month in order to be exposed to the multidimensional nature of health problems, their origins. With the family and the need for adopting a comprehensive approach to health problems. In the course of this phase of training, the students will also develop an appreciation of the need for reference to specialised care facility in selected cases, thus enabling the students to understand the limitations as well as the strengths of general practice. 7.6.4 The Committee also agrees with the recommendation of the MCI that the students must be posted in the accident and emergency sections of the hospital in order to become proficient in problem diagnosis and treatment of acute cases. This posting would also provide experience of the legal and social aspects of medical care. It is very important that senior staff should be availa-ble in this section not only to provide emergency care but to also impart on the spot teaching to the students. 7.6.5 The Committee wishes to emphasise that when a student is posted in a community health facility either during the under-graduate course or during, the Internship, the responsibilities for teaching him in the community setting must be shared by the relevant departments. The importance of community health can be restored only if the entire faculty demonstrate a basic commitment to this objective in the education of the student. 7.6.6 There is increasing concern that the curriculum is not sufficiently inter-disciplinary in nature. The Committee recognises the difficulties of inter disciplinary and integrated teaching. It is expensive in terms of faculty time but more important than any other factor is the concern of the faculty to see that an integrated view of health problems is presented to the students in the most attractive manner. Changes in the curriculum are needed to permit teachers from different disciplines, when ever such an opportunity arises, to combine together in teaching selected topics. The Committee envisages that clinical teachers will participate freely in the teaching of basic sciences drawing attention to the applied aspects of basic medical sciences. Likewise, the Committee feels that the participation of pre-clinical departments in seminars and didactic teaching sessions on clinical problems will greatly facilitate inter-departmental teaching. When all is said and done, integrated teaching succeeds not in the framing of a curriculum but ultimately when there is a change in the minds and hearts of teachers themselves. 7.6.7 In this connection special attention needs to be paid to areas that are essentially inter-disciplinary in character. Clinical Pharmacology, Clinical Virology, Clinical Immunology. Clinical Genetics and Clinical Psychology are examples in this category and efforts must be made to encourage the establishment of units or departments for this purpose. Curriculum of post-graduate education 7.7 In addition to the well-defined and age-old post-graduate courses in the groups of clinical and non-clinical subjects there are post-graduate courses in Preventive and Social Medicine/Community Health and Health and Hospital Administration, for which a strong need is being felt and which are also receiving wide recognition and acceptance. In these courses, certain areas merit special attention. These include demography and population dynamics, study of social, psychological and other environmental factors, group inter-action and behaviour, social psychology, health-economics, health statistics, health legislation, environmental sanitation, principles of epidemiology, public health administration and managerial sciences. In addition to these, the subjects covered in these courses are problems relating to occupational hazards, organisation of health services, social security, and the principles and practice of planning,

implementation, monitoring and evaluation of health programmes in general and in special areas such as health education, nutrition, family planning etc. The basic approach in these courses is that of developing adequate knowledge to make community diagnosis and management of health problems with the objective of promoting positive health, preventing disease and disability and to provide comprehensive medical care. Specialists in these fields are required for various administrative, research and teaching responsibilities. Separate institutional goals need to be worked out on the basis of competency required by those holding these positions. 7.7.1 The other area which needs to be gone into is that relating to post-graduate courses in the field of general practice/family medicine. In the present context, when the country is committed to the goal of Health for All by the year 2000 through the strategy of primary health care on a universal basis, it is all the more necessary that a cadre of suitably trained manpower is developed, which would be capable of delivering comprehensive and integrated health care at the family level. The Committee strongly recommends that this speciality, which already been approved by the MCI, should be further developed so that an increasing number of students pursue higher studies in this area. 7.7.2 In view of the need to enlarge opportunities of training in Public Health and Tropical Medi-cine, the Committee recommends that atleast six Regional Institutes, on the pattern of the All India Institute of Hygiene and Public Health and the School of Tropical Medicine, Calcutta, each imparting integrated training in public health and tropical medicine, should be established in the country. As avenues and career prospects in these areas are rather limited at present, the Committee recommends that the Central and the State governments should provide suitable incentives to attract a progressively growing number of candidates to these disciplines. Medical Education Units 7.8 In order to effect the changes in the institutional goals and curriculum, teaching methods and evaluation reforms (to be described later), the Committee believes that it is necessary that each medical college should have a medical education cell or unit attached to it. To make a beginning in this direction, it is suggested that such units or cells be developed on a regional basis in selected institutions where sufficient interest exists among the faculty and the students in bringing about the much-needed educational reforms. Such units should have a core staff of full-time personnel who are well-versed in educational sciences, in methods of educational management, educational technology etc. But they alone cannot bring about the desired changes without the faculty working in close liaison with them in restructuring the educational process. This recommendation of the Committee is closely related to another recommendation made elsewhere in this Chapter dealing with the setting up of National Teacher Training Centres, in different regions of the country. Teaching and Learning with special reference to Instructional Technology 7.9 It is well-known that each student has his own style of learning. Therefore, in order to maximise learning, the teacher has to ensure the appropriate environment for maximum learning to take place and to adjust his methods and technologies suitably. Having constructed a curriculum that matches the institutional goals, it is necessary that a teacher should be able to deploy, in a sound and perceptible manner, the methods and tools of instruction available to him. He has to select judiciously and use skillfully the available technologies. This implies that the teacher should be familiar with a range of instructional methods and their potential. These include didactic lectures, group discussions, laboratory work, clinical work, field work etc. The learning setting is equally related to the achievement of a specified educational objective.

7.9.1 At the present time, any medical person after acquiring post-graduate qualification can be appointed as a teacher irrespective of the fact as to whether he possesses the requisite aptitude and efficiency in teaching. It is widely recognised that the efficiency of an average teacher can be markedly improved by training him in pedegogic skills and techniques. This is an investment which the Committee feels should be made in the larger interests of improving the quality and relevance of medical education in the country. The Committee recommends that a number of Teacher Training Centres may be established on a regional basis. Six to eight such regional centres to begin with, would suffice the present needs, the number can be increased as time passes and adequate momentum is gained. 7.9.2 Of equal importance is the development of instructional materials and media appropriate for a given learning situation, in our country we have been depending to a large extent upon the "lecture" as a major instructional medium. While the value of this method is well-known, its limitations should also be recognised and an attempt should be made to enrich the quality of teachers by introducing a variety of other his true instructional methods and aids which are now available. There is, to-day, virtually a revolution in educational technology and some of the proven methods and aids should be introduced into the medical educational system. Of great importance in this connection is the use of self-learning devices and self-evaluation techniques. Simulation methods have also been introduced. Synchronised audio-visual slides, video-tapes and television are also being effectively deployed in education to-day. The Institute of Pathology of the ICMR has developed some of these technologies from indigenous sources and has already supplied educational materials in the medical and health field to a variety of institutions and organisations. This Institute could play an important part in facilitating the enhanced use of audio-visual technology in medical education. 7.9.3 The Committee wishes to emphasise that the preparation of teaching and learning materials involves a great deal of efforts. The examples chosen, if they are derived from local experiences, will greatly enhance the relevance of teaching. The Regional Teacher Training Centres, recom-mended earlier, could also be charged with the responsibility of preparing the requisite introductional materials in collaboration with the audiovisual technology unit/division of the Institute of Pathology of the ICMR. The services of professional associations and societies and the National Academy of Medical Sciences and other expert bodies in the country could also be utilised for their preparation. Evaluation 7.10 Traditionally, evaluation in medical education is designed to certify competence in the practice of medicine and can be regarded as a way of protecting the public from sub-standard practitioners in art and science of medicine. In the educational sense, evaluation has another dimension, namely, to measure to what extent the objectives of medical education have been fulfilled and to reveal the deficiencies in the educational process for correction. In addition, evaluation can help individual teachers and their departments in improving the quality of education.

7.10.1 In medical education, evaluation can be related to: - (a) the product (under-graduate and postgraduate students) ; (b) teaching ; and (c) the process of evaluation. Evaluation at times can also be used as a tool to promote learning (formative evaluation). Product Evaluation 7.10.2 In the existing system of evaluation of the students, there is a significant element of sub-jectivity while conducting the examinations. Often there are allegations of favouritism, victimisation, inaccurate assessment which particularly happens while conducting oral and practical examinations and clinical tests. It is, therefore, essential that the examination should be made objective as far as possible and the evaluation system should assess all the areas of knowledge and skills related to the curriculum and institutional goals. Further, it would be desirable to establish uniform standards of evaluation, in the medical institutions all over the country. In this context, the Committee recommends, as a long term goal, the establishment of a central, national level, independent body for conducting the MBBS examination, so as to achieve not only uniform standards in the ultimate certification of MBBS students but also to monitor the implementation of institutional goals recommended by the Committee elsewhere and to ensure that the curricula of medical courses bring to the fore, the national Health, Medical Education and Health Manpower policies as may be adopted by the Government, from time to time. If this cannot be achieved immediately, atleast uniformity should be maintained in all the medical colleges in each State. The structuring and administration of suitable multiple choice questions (MCQs) can, to some extent, serve the purpose of objective assessment. However, it is experienced that presently a large number of teachers in our country are not suitably trained in the discipline of MCQs. It is, therefore, recommended that the Regional Teacher Training Centres, referred to above, should train the teachers in the techniques of constructing multiple choice questions. The medical education units proposed for each medical college could also undertake the responsibility of training the teachers and, later, to conduct item-analysis of the scores obtained by the students and gradually improve the construction of MCQs. At the national level, a Central Cell, which should be appropriately linked with the National Board of Examinations could monitor and oversee the evaluation techniques and establish inter-action with the Regional Teacher Training Centres and the State level medical education units. Till such time as the proposed Universities of Health Sciences recommended in Chapter IX, are established, an identified university, in every State which has more than one university, should be made responsible to ensure uniformity in the evaluation of all the students in the State. The aforesaid university could be the one which has been entrusted with the responsibility of conducting the Pre-medical Test for admissions to all the medical colleges in the State. 7.10.3 The limitations of the MCQ test should, however, be realized and the possibility of com-bining such tests with short essay type and long essay type questions should be explored and a judicious balance between them ensured. 7.10.4 The Committee appreciates the relevance of internal assessment as a tool for motivating the students to learn and for assessing their day-to-day performance, which will contribute to the achievement of the final goals. However, it is observed that in practice many limitations are imposed on the system when it is used as a tool for periodic assessments or when it contributes towards the final assessment of the students. Nevertheless, it is recommended that due weightage should be given to day-to-day assessment.

7.10.5 There is need for continuous improvement of the evaluation techniques as no single technique is perfect. Efforts should be made to introduce newer techniques for the assessment of problem-solving abilities and clinical skills. It is suggested that in the Regulations of the MCI for professional examinations, the above recommendation should be suitably incorporated. Evaluation of teaching 7.10.6 The Committee feels that the teaching methods used, the curriculum, the learning experience provided and the performance of both the staff and the students (under-graduates, and post graduates) should be kept under constant evaluation in terms of the institutional goals and the national Health and Medical Education policies. The appropriateness of the teaching methods, the goals, the effectiveness of the teachers in promoting may be evaluated by inviting students to provide written comments or by asking them to answer a structured questionnaire. The findings may be reviewed by the faculty. A well established assessment system shall contribute to improved teaching. The involvement of students in the evaluation process will engender them, over time, with greater responsibility. Process of Evaluation 7.10.7 The validity, objectivity and practicability of implementation of the evaluation process would vary from situation to situation and from time to time. Therefore, whatever evaluation system is ultimately introduced, it would be necessary to review and appraise it periodically, to bring about such modifications therein as appear necessary.

CHAPTER VIII RECOMMENDATIONS IN REGARD TO MATTERS NOT COVERED BY THE

COMMITTEE'S TERMS OF REFERENCE

8. Though not specifically called upon to do so, the Committee considers it relevant to also offer its views on certain issues not included in its terms of reference. These are briefly discussed in the paras following.

Incentives to doctors for service in the rural areas

8.1 The Committee observed that inspite of the various incentives offered to the doctors to serve in the rural areas, the response, so far has not been very encouraging. There are areas in each State in which the population is either underserved or almost entirely denied appropriate health care services. The more mentionable among the reasons usually advanced by doctors for not accepting opportunities to serve in rural areas are as follows :—

(a) suitable accommodation, educational facilities, civic amenities (transport, drinking water, electricity etc.) are not available at the rural stations of posting;

(b) essential drugs and basic bio-medical equipments are not provided in the rural health centres;

(c) the unethical activities of unqualified medical practitioners of the various systems of medicine, practising in the villages hinder the functioning of the allopathic doctors;

(d) as compared to the opportunities in the rural areas the private medical practitioners can earn much more in the urban areas;

(e) that they have received hospital based curative training and are not adequately equipped to practise community medicine; and

(f) medical care is the responsibility of the State Governments, whereas the academic policies and educational regulations are the concern of the Universities. There is not enough dialogue between the two. Medical education is not adequately related to the needs of the health services, specially in the rural areas.

8.1.1 The Committee reviewed the various incentives being provided by the different State Governments to doctors posted in the rural areas. Some of these are :— (a) special allowance, (b) rent free accommodation; © preference for admissions to post-graduate courses, after rendering rural service; (d) higher age limit for retirement, for those serving in PHCs etc. 8.1.2 The Committee also noted that some banks grant loans to doctors seeking to set up private practice in rural|semi urban areas. 8.1.3 To provide further encouragement for service in the rural areas the Committee recommends that additional incentives, as listed below, may also be provided to doctors: (a) suitable weightage should be given to those who have served in the rural areas for admission to the post-graduate courses, as already recommended in Chapter III; (b) free accommodation, including water and electricity, should be provided to doctors serving in the PHCs; © the children of doctors posted in the PHCs. etc, should be enabled to continue their studies, whether in school or in college, through grant of special allowances to doctors to suitably cover

such expenses; (d) grant of special rural allowance, not being less than 25 per cent of basic pay; (e) the service in the rural areas should be given double credit, upto a maximum of 5 years, for pension purposes as well as for promotions; (f) soft loans in adequate amounts should be provided by Government to doctors setting up practice in the rural areas on the same terms as are available to unemployed engineers etc. As in the latter case, the seed capital should also be provided through the State Financial Corporations etc.; (g) the rural dispensaries and hospitals should be provided with minimum essential equipments and drugs as the lack of basic facilities is one of major factors contributing to the frustration of the medical personnel appointed at rural stations; (h) the Committee is of the opinion that doctors who seriously take up and settle down to work in the rural areas should be adequately assured of security and recognition; and (i) after serving in a rural area for atleast three years, the incumbents should get urban postings, if they so desire. Medical ethics 8.2 The code of Medical Ethics, formulated by the Medical Council of India, was reviewed by the Committee. The Committee, after going through the various provisions of the Code, is of the view that it is adequately comprehensive and requires to be enforced strictly. The Committee accordingly recommends that the Government of India should take effective steps to enable the MCI to legally enforce the Code. Continuing Medical Education 8.3 All that is required to be learnt by a doctor cannot possibly be taught in a medical college. It is in this context that in Chapter VII, the Committee has recommended the need for inculcating in the students a desire to continue learning, as a life4 long process. As for back as in 1946, the Bhore Committee observed that "new ideas and new discoveries in medicine come forward with such bewildering rapidity that it is hardly possible for the busy doctor to keep abreast even of those advances in knowledge which are necessary for him in the daily carrying on of his profession". The Mudaliar Committee (1961)5 observed that the efficiency of any medical service in a country is to be judged from the point of view of efficiency to the general practitioner and if, therefore, the people are to be served well with upto date methods of diagnosis and treatment, the responsibility for keeping these practitioners at a level of efficiency is obvious having due regard to the rapid scientific advances in the faculty of medicine."

8.3.1 The planning and implementation of continuing education programmes should be a collaborative activity between the medical college (s), the professional associations and the State Health and Medical Education Departments. Varying approaches will be required for providing such education to different types of personnel, viz. specialists, general practitioners, teachers, doctors serving in the vertically organised national programmes, administrators and planners, etc. The Committee feels that while the Medical and Health Education Commission recommended for establishment (in Chapter IX) may be the apex body for providing the required directions in regard to the organisation of these programmes a central coordinating agency for planning, organising and monitoring such activities should be identified by the Government of India and entrusted with this crucial responsibility. This agency should establish a small advisory group of experts, including teachers, representatives of professional associations and councils, health administrators etc. and draw up, every year, a carefully considered list of courses which require to

4 Health Survey and Development Committee, 1946 5 Health Survey and Planning Committee, 1961

be organised and run at the various medical and health institutions in the country. This group should also devise procedures to evaluate the various programmes to determine whether the objectives behind the programmes are being achieved and if not, what correctives are necessary to be introduced to make them more effective.

8.3.2 The central coordinating agency may arrange continuing medical education programmes through the various medical colleges, Health and Family Welfare Training Centres run by the Central Government, the Post-graduate Medical Institutes at New Delhi, Pondicherry and Chandigarh, the I.C.M.R., professional associations, the Medical Council of India, Indian Medical Association (College of General Practitioners), the Indian Association for Advancement of Medical Education, National Academy of Medical Sciences etc.

8.3.3 The Committee observed that so far, continuing medical educational programmes have been sporadic and arranged by institutions|associations with the help of rather limited educational material available with them and not on the basis of any well-conceived programme. In the view of the Committee, a special fund should be created for arranging continuing medical education programmes all over the country. This fund can be operated by the coordinating agency referred to in the previous paragraphs. The Government of India, the State Governments, professional associations, philanthropists and international agencies may also provide funds by way of grants/donations towards the proposed fund. 8.3.4 The Committee took note of the fact that there have not been frequent visits by teachers in the medical colleges to the district|taluk or other peripheral hospitals for arranging specific purpose seminars in regard to specially identified health problems faced by the health administrators, doctors working in the health service system, also involving the private practitioners. Thus there is need to encourage peripatetic teams from the medical colleges to visit surrounding areas to discuss problems and suggest locally viable solutions to problems faced by the practitioners. In this context, the Committee recommends that continuing medical education programme should be arranged in the district|taluk level hospitals for the benefit of practising health professionals. A phased programme should be launched to develop a national information grid through which each region of the country should be made self-sufficient in providing information in regard to the latest advancements in the field. 8.3.5 The Committee also recommends the need for strengthening the National Medical Library and for setting up of libraries in the district hospitals which should contain bibliographic refe-rences, suitable stocks of audiotapes, sound-slides and programmes instruction materials, self-learning assessment devices and other aids to independent learning. Government should provide suitable assistance to the Indian Medical Association to enable it to enlarge the publication of its Journal and for making it easily available to the medical professionals and students all over the country. "Swasth Hind" produced in Hindi and English by the Central Health Education Bureau, can also be improved in content and quality. The Committee feels that such a publication on health problems relevant to the community should be provided free of charge to all medical practitioners as is being done in some developed countries. Regular talks, on specially identified topics, over the radio or T. V., by experts may be arranged for the benefit of medical practitioners and the public. 8.3.6 Realising the crucial importance of continuing education programmes, the Committee feels that unless some incentives are provided, the present lack of interest towards such courses by the medical practitioners will continue. In this context, the Committee recommends that in the case of government servants, due weightage should be given for promotions, crossing of E.B. etc to those who have been keeping their medical knowledge upto date by attending such courses. They

should also be paid TA/DA for attending such courses. They should also be paid TA/DA for attending professional conferences aleast once a year. There should be in-built procedures in the various health service organisations to depute, periodically, medical and health professionals to attend continuing educational programmes. Similarly private practitioners may be encouraged and enabled to participate in professional programmes. 8.3.7 The Committee feels that while such continuing education programmes for various cate-gories of medical and health professionals should be organised, there is also the need for inter-professional education programmes, leading to improvements in team approaches, better appreciation of the role of various categories of health workers in the health care services etc being undertaken. In the opinion of the Committee, improvements in health care can be achieved more effectively if the various categories of health personnel are trained to work together, at all levels of functioning. Medical Services to be essential services 8.4 The Committee is of the view that hospitals and medical colleges should be declared essential services outside the purview of the industrial laws. This is necessary to ensure uninterrupted health care services and the training and teaching of medical students.

CHAPTER IX IMPLEMENTATION OF RECOMMENDATIONS

9. At its very first meeting the Committee observed that a good number of the existing problems relating to declining standards of medical education in the country were due to inadequate imple-mentation of the existing Regulations of the Medical Council of India. It was noted that the pro-visions of the Indian Medical Council Act 1956, were no longer adequately effective. By way of example, the Indian Medical Council Act, 1956 does not have the authority to prevent the establishment of new medical colleges and comes into the picture only when the newly created institutions seek recognition of the degrees to be awarded by them. It was further observed that the recommendations of a number of Committees established in the past did not appear to have been fully implemented. The Committee was accordingly of the view that its recommendations would have no better value than those of similar bodies established in the past unless the Govern-ment of India undertook to consider and implement them on a time-bound basis. After taking into consideration the various problems relating to medical and health education, the Committee makes the recommendations listed hereunder:- 9.1 At present, under Item 66 of List I of Seventh Schedule to the Constitution, the Union Government is empowered to take necessary action for coordination and determination of standards m institutions for higher education or research and scientific and technical education. Medical Education is however included in List III—Concurrent List—in the Seventh Schedule of the Constitution. Considering the obtaining state of affairs and growing evidence of the lack of a coordinated plan of action in all matters relating to under-graduate and post-graduate education, the Committee is of the considered view that, ideally, the needed education reforms can be brought about and effectively secured only if "Medical Education", is brought on the Union List so that the Central Govt. is enabled to evolve and implement fully coordinated plans, to bring about rapid improvements in the standards of medical education as well as be able to see that the production of medical and health professionals is largely, if not entirely, in tune with the actual requirements of the country. 9.2 The maintenance of high standards of medical and health education, production of profes-sionals of various grades of skill and competence in the required number, educated, trained and oriented to efficiency tackle the priority health problems of the country is, for obvious reasons, not a one time affair, but involves a dynamic process of constant monitoring, review, evaluation and enforcement of remedial action. In this context it would be necessary to constitute an adequately empowered authority at the Centre. Such a body may be called the Medical and Health Education Commission, as recommended earlier by the Shrivastav Committee in 1975.*6 Ideally, such a body would require to have a statutory basis. 9.3 The proposed Medical and Health Education Commission should be responsible for drawing up well-considered plans for health manpower development, in consultation with the Central and State Governments, existing professional Councils and other concerned agencies. It should also

*Report of the Group on Medical Education and Support Manpower—1975.

be responsible for the drawing up and implementation of continuing educational programmes for the various categories of medical and health-personnel; securing effective coordination in the functioning of' the existing /statutory Councils viz. Medical Council of India, Dental Council of India, Pharmacy Council of India, Indian Nursing Council/etc. to ensure a harmonious approach and the production of professionals as per assessed manpower requirements. In the initial phase, the requisite coordination may be achieved through consultation while, in the long run, it may be necessary to bring about suitable amendments in the related statutes to give overpowering authority to the Medical and Health Education Commission. Allocation of funds and disbursement of grants to medical and health institutions would also require to be decided in consultation with this central authority. 9.4 To begin with the proposed Commission may be a small compact body whose Chairman should be a leading personality in the field of health administration, education or research. Its members may include selected representatives of the Central and State Governments, universities and the office-bearers of the major professional associations. The Presidents of the existing statutory Councils should be made members of the Commission in their ex-officio capacity. The Commission should be responsible for the constant monitoring, review and evaluation of all aspects relating to medical and health education, in the various fields, and should also be charged with the responsibility of assessing medical and health manpower requirements. In due course, as the proposed body gets established as a statutory authority, it may enlarge its functions to become the one Central authority responsible for overseeing and planning all aspects of medical and health education. 9.5 Presently, the majority of the medical colleges are run by the State Governments or by private bodies, being affiliated to local universities for the grant of degrees. Only a handful of medical institutions are directly run and managed by the Central Government. In actual functioning, the concerned universities have little or no control over the day-to-day functioning of the medical institutions which do not possess adequate autonomy, so essential to the engendering of a health and productive academic environment. Furthermore, in the various educational and training institutions of the modern and the Indian systems of medicine, nurses, pharmacists and the various other categories of medical and health personnel are trained to function in isolation, without there being any mechanism for the drawing up of an integrated, common action plan. Consequently, there is visible variation in the objectives and institutional goals pursued by the various educational institutions. This is due to the fact that there is no common authority to guide, assist or direct the various institutions in regard to manpower planning; to advise them about the number of professionals required annually to support the health services of the country etc. In order to fill up this serious lacuna and to bring about the vitally needed coordination, it is essential that the Central Government should establish Universities of Health Sciences to which all the various medical and health training institutions, falling within the jurisdiction of such universities, should be affiliated. The establishment of Agricultural Universities, in recent years, has amply demonstrated the vast benefits which flow from coordinated functioning. However, as the establishment of state-wise Universities of Health Sciences may take considerable time, it is recommended that, to begin with, the Central Government may establish one such university on a trial basis, to cover all the medical and health institutions in a given State or for a region com-prising a group of contiguous States and Union Territories. On the basis of the experience gained from the functioning of such a university, the experiment could be extended in due course, so that medical and health institutions in every State| group of contiguous States|UTs are covered and controlled by such universities. Besides bringing about the extremely necessary coordination, the proposed universities could become responsible for launching well-considered initiatives in the field of Health planning, Health Administration, Health Economics etc., and to ensure that the concept of the Health Team is indicated in the formative period of training of all medical and

health personnel, of various grades of skill and competence. 9.6 The Committee is also of the view that the Central and State Governments would require to review the existing salary structures of teachers in the medical and health training institutions and to revise the same with a view to attracting the best available talent. Special incentives would require-to be afforded to teachers in the basic sciences in which areas there has been continuing shortage in the recent years. 9.7 The State Governments would require to provide adequate funds to ensure that interns and doctors posted at the rural health centres are provided with suitable accommodation and other conveniences to enable them to discharge their responsibilities, effectively and efficiently. Simul-taneously, it would also be necessary to ensure that primary health centres, rural training centres etc. are edequately equipped with the necessary machines and equipments and provided with the requisite supply of drugs. 9.8 The State Governments should take immediate steps to place the rural training centres|pri-mary health centres attached to medical colleges under the administrative control of the concerned medical institutions while ensuring that the career prospects of the medical officers and other staff posted at such centres are not adversely affected by such an arrangement. 9.9 Immediate steps may be taken by the Government of India to bring about suitable amendments to the Indian Medical Council Act, 1956, specially with a view to ensuring that no medical institution can be established anywhere in the country without the prior approval of the Medical Council and the Government of India. Inter-alia, various other amendments in the Act ibid are also required, to improve its operational effectiveness. 9.10 The Medical Council of India would require to constantly inspect and review the functioning of medical institutions and take an uncompromising view regarding recognition of medical degrees, college-wise maintenance of standards of teaching and training and de-recognition of sub-standard institutions. The Council would also require to gear up its machinery to possess itself with upto-date information regarding the functioning of each medical college and to vigorously enforce the registration of doctors, to collect essential manpower data etc. Besides, the Council should take urgent steps to effectively enforce the Code of Medical Ethics, formulated by it. Towards this objective, the Central Government should provide such, assistance as may be necessary to the Council. 9.11 Till such time as the Indian Medical Council Act, 1956, is amended, and the proposed universities of Health Sciences established, the existing universities may not grant affiliation to any new medical college unless the Medical Council of India| Government of India have ap-proved the establishment of the concerned institution. 9.12 Taking note of (i) the existing domiciliary restrictions imposed by the State Governments in the matter of selections of doctors, teachers etc., and (ii) geographical maldistribution of available health personnel, the Committee recommends the creation of an All India Health and Medical Service. 9.13 In order to procure reliable health manpower data to assess current needs as well as to plan the requirements for 2000 A.D., the Committee recommends that Health Manpower Development and Research Bureau should be established by all State |U.T. Governments and at the Centre. 9.14 The Committee recommends, for the consideration of Government, the approach set out in

the paper furnished by a Member (Annexure V) in regard to the implementation of the recommendations. 9.15 Having reviewed the recommendations of Committees established in the past, the Com-mittee feels that it would necessary for the Central Government to establish a suitably constituted cell, to process its recommendations on a time-bound basis.

Sd R. D. AYYAR

I.D. BAJAJ P. N. CHHUTTANI

O.P. GUPTA L.B.M. JOSEPH M. M. MEHTA

V. RAMALINGASWAMI RAMESHWAR SHARMA

Y. P. RUDRAPPA B. N.SINHA

H. D. TANDON K. N. UDUPA

P. N. WAHI N.N. VOHRA S. J. MEHTA

CHAPTER X SUMMARY OF RECOMMENDATIONS

National Entrance Examination for M.B.B.S.

(1) A National Entrance Examination, which should be exclusively of an objective type, for admission to the MBBS course should be established (Para 2.1).

(2) No institution should be allowed to charge capitation fees from candidates seeking admission to the MBBS/Post-graduate course (Para 2.1.1).

(3) The concerned examining bodies should hold the feeder channel examinations within a stipulated time-schedule to ensure that the results of the various examinations are available before the date of the National Entrance Examination (Para .2.1.2).

(4) The Government may identify a suitable central institution,, preferably an autonomous body, to conduct the National Entrance Examination (Para 2.1.3).

(5) The Entrance Examination should provide tests, in the English medium, in Physics, Chemistry, Biology and General Knowledge (Para 2.1.4).

(6) Adequate advance notice of the time-schedules of examinations should be given by the concerned academic institutions to enable candidates to prepare for the entrance tests and make timely travel arrangements (Para 2.1.5).

Reservations

(7) Reservation of seats for admissions to the MBBS course, for SC|ST candidates, may be fixed by the State Governments with reference to the SC|ST population of the State, within the Government of India's policy directions; for other categories of beneficiaries, reservation may be made only with the prior sanction of the Medical Council of India [Para 2.2.1 (a) & (b)].

(8) The aggregate of reservation of all kinds should not exceed 33-1(3% of the total number of seats available in each college [Para 2.2.1 (C)].

(9) There should be no further relaxation of the minimum qualifying marks of 40% for SC/ST candidates. Special coaching facilities may be provided for the benefit of such candidates [Para 2.2.1 (d) and (f)].

(10) There should be no carry forward of reserved seats of any category from one year to the next and all such seats which remain unfilled should be utilized by admitting eligible SC/ST candidates from the neighbouring States|Union Territories. Unutilised seats should be thrown open to general category candidates [Para 2.2.1 (e)].

(11) Domiciliary restrictions for admission to the MBBS course should be progressively removed. To begin with 25% of the seats in each institution may be open to the admission of candidates on an all India basis, of which a suitable percentage may be earmarked for candidates from the backward areas (Para 2.3.).

Admissions to the Postgraduate Medical Courses

(12) A National Entrance Examination should be conducted for admitting candidates to the various post-graduate courses. The test should be of an objective type (Para 3.1).

Reservations and Domiciliary Restrictions

(13) There should be no reservation of seats for SC|ST candidates, nor any domiciliary restrictions or pre-conditions of compulsory rural service for admissions to the postgraduate courses. However, candidates who have done 2 years of rural service may be given additional credit|weightage, to be determined by Government. Special coaching|counselling facilities should be provided to SC|ST candidates in-order to enable

them to secure admission to Postgraduate courses. Since doctors in Government service may not be able to compete with the fresh graduates at the National Entrance Examination for postgraduate courses, suitable weightage, say upto 5%, may be given to such candidates, while determining inter-se merit. They may also be enabled to undergo in-service training in identified specialities and to appear in NAM/NBE examinations to obtain higher qualifications. (Paras 3.1 to 3.4).

Duration of the Under-graduate Medical Course & Internship

(14) The present duration of the MBBS course should be maintained. There appears no basis for starting an intermediate medical course or to reduce the existing duration of the MBBS course (Paras 4 & 4.1).

(15) The period of one year Internship, including six months service in the accredited district taluk hospitals and rural centres, should not be diluted and the responsibility for providing such training as well as the requisite infrastructural facilities must rest entirely with the medical colleges and the respective State Governments. Out of 6 months Internship in the medical college hospital, 4 months should be for rotating training, with structured content, and 2 months for training in an elective subject speciality of the stu-dent's choice. (Para 4.2).

(16) Candidates must pass a formal in-house clinical examination at the conclusion of Internship, for grant of a Degree (Para 4.2).

(17) Professors and senior faculty members in the colleges should be deputed to PHCs|Distt. Hospitals etc. to supervise the training of the students during their Internship period (Para 4.2.3).

(18) The State Government|Union Territory Administrations should take suitable steps to protect Interns and young doctors posted to rural areas from harassment by local unqualified practitioners (Para 4.2.4).

Duration of Post-graduate Courses

(19) The minimum duration of the post-graduate degree and diploma courses should be three years and two years, respectively, after full registration. The existing system of one year of Housemanship should be abolished (Para 5).

Thesis (20) In view of fact that the whole systems of thesis writing, as it is being actually

implemented at present, falls short of the expectation of having it as a compulsory requirement, the Committee recommends that it should be compulsory for non-clinical subjects and optional for clinical subjects. In the latter case where a student opts for and successfully completes a thesis, he should be afforded suitable credit|preference in further ing his career prospects. The success of this approach should be periodically reviewed (Para 5.1).

Residency Scheme

(21) There is no justification for fixing limits of the hours of work required to be put in by the Resident Doctors as the training and service components cannot be separated [Para 6.3(c)].

(22) Resident seats should be determined, department-wise with reference to the employment opportunities and assessed service loads, manpower requirements of specialists, and the clinical facilities actually available The number of seats should be fixed with the prior approval of the M.C.I. [Para 5 & 6.3.(a)].

(23) The period of Junior Residency cannot be treated as regular service till such time as the number of seats in the various post-graduate courses are related to the manpower requirements and actual employment opportunities [Para 6.3. (d)].

(24) The period of service of Senior Residents who secure government service may be counted for pensionary benefits and the breaks, if any, may be condoned. [Para 6.3(e)].

(25) There should be no upper age limit for admissions to the Senior Residency Programme. The maximum age limit for entry into government service should be raised by suitably amending the recruitment rules. [Para 6.3.(f)].

(26) In the case of non-clinical departments, Demonstrators| Tutors may also be appointed against the regular vacancies of Junior Residents and allowed to enrol themselves for Post-graduate qualifications. After securing Post-graduate qualifications, they should be eligible for appointment as Lecturers without having to go through a fresh process of selection, other things being equal [Para 5.3.(g)].

(27) The Committee recommends that the Residents should carry out such laboratory investigations as part of their training [Para 6.3(h)].

(28) There is not need for the clinical Postgraduates to put in three years of further service as senior Residents or Registrars, etc. to become eligible for appointments as Lectures]Assistant Professors (Para 6.4).

Institutional Goals

(29) The Committee recommends the adoption of institutional goals separately for under-graduate and post-graduate courses, which should project the purpose of medical education viz. to train physicians to fit into different levels of health care system and to be able to resolve the health problems of the community (Paras 7.2 and 7.3).

(30) The broad purpose of under-graduate medical education is to train medical graduates who should be general practitioners and would have the capability of providing comprehensive health care to both rural and urban communities (Para 7.4).

(31) As regards postgraduate medical education, the Committee recommends the adoption of institutional goals separately for clinical and non clinical specialities on the basis of competencies required for the specialists, research workers, teachers, etc. (Paras 7.5.1. & 7.5.2).

Curriculum Reform—Under graduate Course

(32) The curriculum should provide opportunities for an education that is problem solving and competence building, and should be the total faculty commitment of the entire medical college (Para 7.6.2.).

(33) The students should be posted in a general practice out-patient department for about a month in order to be exposed to the multidimensional nature of health problems as well as to them to understand the limitations and strength of general practice. They should also be posted in the accident and emergency departments in order to become proficient in the methods and problems of diagnosis and treatment of acute cases under he direct supervision of the faculty (Paras 7.6.3 & 7.6.4).

(34) The entire faculty should demonstrate a basis commitment to Community Health Services. (Para 7.6.5.)

(35) In spite of difficulties in inter-disciplinary and integrated teaching, the Committee recommends suitable changes in the curriculum to permit teachers from different disciplines to combine together in teaching selected topics (Para 7.6.6).

(36) In order that a cadre of suitably trained manpower is developed, which would be capable of delivery of comprehensive and integrated health care at the family level, in the context of the country's commitment to the goal of Health for All by 2000 A.D., the Committee strongly recommends that an increasing number of doctors should be encouraged to seek specialisation in the field of general practice and family medicine (Para 7.7.1).

(37) At least six Regional Institutes each imparting integrated training in public health and tropical medicine on the pattern of All India Institute of Hygiene and Public Health and the School of Tropical Medicine, Calcutta, should be established in the country to meet the shortage of public health personnel. Suitable incentives should be given to attract candidates to this discipline (Para 7.7.2).

Medical Education Cells

(38) Every medical college should have a Medical Education Cell|Unit attached to it in order to effect the changes in institutional goals and curriculum teaching methods, evaluation reforms etc. To make a beginning in this direction, such cells may be developed on a regional basis in selected institutions. (Para 7.8).

Instructional technology

(39) In order to improve the quality and relevance of medjcal education in the country, 6 to 8 Teacher Training Centres should be established on a regional basis to familiarise the teachers with a range of instructional methods and their potential (Para 7.9.1).

Evaluation

(40) The examinations should be made as objective as possible and the evaluation system should assess all the areas of knowledge and skills related to the curriculum and institutional goals. Uniform standard of evaluation all over the country is desirable. In this context, as a long term goal, the establishment of a national level independent body for conducting the MBBS examination is recommended. If that be not possible to achieve immediately, alteast uniformity should be maintained in all the medical colleges in each State. Regional Teachers Training Centres should also train teachers in the process of constructing multiple choice questions. The Medical Education cells proposed for each medical college should also be involved in the process. At the national level, a Central Cell which should suitably be linked with the National Board of Examinations, could monitor and oversee the evaluation techniques. Till such time universities of Health Sciences are established, an identified university in each State should be made responsible to ensure uniformity in the evaluation of all the students in that State. There is also a need for continuous improvement of evaluation techniques as no single technique is perfect (Paras 7.10.2 & 7.10.5).

(41) The Committee recommends that teaching in medical colleges should be kept under constant evaluation (Para 7.10.6).

(42) There is also the need to appraise the evaluation system periodically (Para 7.10.7).

Incentives for service in rural areas

(43) Additional incentives such as free accommodation, water and electricity, children's education allowance, special rural allowance, bank loans at differential rates of interest etc. may be provided to doctors for serving in the rural areas. The rural dispensaries should also have the basic equipment and supply of essential drugs (Para 8.1.3).

(44) Government should take effective steps to enable the MCI to legally enforce the Code of Medical Ethics (Para 8.2).

Continuing Medical and Health Education

(45) The Government may identify a Central coordinating agency for planning,

organising and monitoring continuing education programmes all over the country and a special fund may be created for this purpose (Paras 8.3.1. and 8.3.3).

(46) Continuing medical education programmes should be arranged in the district|taluk level hospitals for the benefit of practising health professionals. A phased programme should be launched to develop a national information grid. [Para 8.3.4].

(47) The National Medical Library should be strengthened and libraries set up in the district hospitals with adequate learning material such as audio-tapes, sound slides, etc. Health publications such as Journal of the Indian Medical Association, "Swasth Hind" etc. should be provided free of charge to all medical practitioners. [Para 8.3.5].

(48) Medical Practitioners in Government service should be encouraged to keep their medical knowledge up-to-date by periodically attending courses on continuing education programmes etc. Private medical practitioners should also be encouraged and enabled to participate in professional programmes. [Para 8.3.6.]

(49) There is need for inter-professional education programmes leading to improvements in team approaches, better appreciation of the role of various categories of health workers, etc. (Para 8.3.7).

Medical colleges and medical services to be essential services

(50) Medical colleges and hospitals should be declared essential services [Para 8.4].

Medical Education to be brought under Union List of the Seventh Schedule (51) The needed educational reforms can be brought about and effectively secured

only if Medical Education is brought on the Union List in the Constitution [Para 9.11.]

Appointment of Medical and Health Education Commission (52) An autonomous, Medical and Health Education Commission should be

established by the Centre and be made responsible for the coordination, planning and implementation of various medical and health education programmes in all branches of Health Sciences, planning for the development of health manpower allocation of funds and disbursement of grants to medical and health institutions etc. [Paras 9.2 & 9.3].

Establishment of Universities of Health Sciences

(53) The Central and State Governments should establish Universities of Health Sciences in order to bring about coordination between the various educational and training institutions of the modern and various Indian Systems of Medicine, nurses, pharmacists, etc, Li the beginning the Central Government may establish one such University on a trial basis, to cover all the medical and health institutions in a given State or for a region [Para 9.5]

Review of Salary Structures of teachers

(54) The Central and State Governments should review the existing salary structures of teachers in the medical and health training institutions and revise the same with a view to attract the best available talent [Para 9.6].

Maintenance of Standards of Medical Colleges

(55) The Medical Council of India would require to regularly review the functioning of medical institutions and take an uncompromising view regarding the recognition of medical degrees, college-wise, maintenance of standards of teaching and training and de-recognition of institutions which do not maintain the requisite standards[Para 9.10.]

Formation of All India Health and Medical Service (56) The Committee recommends the constitution of an All India Health and Medical

Service [Para 9.12]. Establishment of Health Manpower Development & Research Cells

(57) The Committee recommends the establishment of Health Manpower Development and Research Cells in the States and U.Ts. and at the Centre [Para 9.13].

ANNEXURE I

No. U. 12012|28|81-ME(Policy) GOVERNMENT OF INDIA

MINISTRY OF HEALTH & FAMILY WELFARE (Department of Health)

New Delhi, the 8th September, 1981

RESOLUTION There has been large-scale expansion of facilities for medical education in the country at under-graduate and post-graduate levels during the past three decades. This development has enabled the country to augment the health services. However, despite this achievement, certain distortions have crept into the medical education system making it inadequately responsive to the health needs and priorities of the country. On more than one occasion, the Prime Minister has emphasised how important it is that the medical education system should be reviewed so that it harmonises wholly with the over-riding objective of health care besides ensuring that the needs of the many prevail over those of the few. 2. A review of the present medical education system has become necessary in the context of the national commitment to attain the goal of "Health for all by the year 2000 A.T). through the uni-versal provision of Primary Health Care. In this context, the resurgence of some of the tropical diseases, the predominantly hospital-based rather than community-oriented education, the need for preparing medical personnel to respond effectively to the health problems in the rural areas, the imbalance in the proportion of general practitioners to post-graduate and the entire process of medical education at under-graduate and post-graduate levels, including the goals, instructional methods and evaluation procedures, necessitate an urgent and careful review. 3. The Government have, therefore, decided to the health problems in the rural areas. The composition of the Committee is as under .- — 1. Dr. Shantilal M J. Mehta, Chairman Retd. Director, Jaslok Hospital, Bombay, 2. Dr.I.D. Bajaj, Member Director General of Health Services, New Delhi. 3. Prof. V. Ramalingaswami, Member Director General, Indian Council of Medical Research, New Delhi 4. Prof. H.D. Tandon, Member Director, All India Institute of Medical Sciences, NEW DELHI 5. Dr. L.M.B. Joseph, , Member Principal, Christian Medical College, Vellore. 6. Dr. M.M. Mehta, Member Member of Parliament, 53 % North Avenue, New Delhi 7. Dr. O.P. Gupta, Member Direcor of Medical and Research, Gandhinagar, Gujarat 8. Dr. Y.P. Rudrappa, Member Director of Medical Education and Research, Bangalore 9. Dr. B. N. Sinha, Member President, Medical Council of India, Kotla Road, New Delhi. 10. Dr. Rameshwar Sharma, Member Principal, S.M.S. Medical College, Jaipur. 11. Dr. P.N. Wahi, Member

Executive Director, Indian Association for the Advancement of Medical Education, New Delhi 12. Dr. P.N. Chuttani, Member 22, Sector 4, Chandigarh 13. Col. R.D. Ayyar, Member 139|A, -Kelakshtra Colony, Basant Nagar, Madras 14. Dr. K.N. Uduppa, Principal, College of Medical Science, Varanasi. 15. Shri N.N. Vohra. Member- Secretary Joint Secretary, Ministry of Health & Family Welfare, New Delhi 4. The terms of reference of shall be as under :— (i) to review the current admission procedures (including entrance tests) and domiciliary restrictions for admissions to under-graduate and post-graduate courses and to make suitable recommendations separately, in regard thereto; (ii) to suggest measures aimed at bringing about overall improvement in the under-graduate and post-graduate medical education, paying due attention to: (a) institutional goals; (b) content, relevance and Duality of teaching and training and learning settings; and (c) evaluation systems and standards; (iii) to recommend the optimum duration of under-graduate and post-graduate courses of study separately; (iv) to examine the existing Internship programme and to recommend its future pattern; (v) to review the working of the Residency Scheme along with the Housemanship programme and to make recommendations regarding a uniform pattern of post-graduate training; (vi) to examine the current requirement of Thesis or Dissertation as an essential part of post-graduate medical education and to make suitable recommendations in regard thereto; and (vii) to examine the feasibility of a period of service in the rural areas for medical graduates and post-graduates. 5. The Committee will also evolve realistic projections of medical manpower requirements (MBBS doctors, general specialists and super-specialists) during the Sixth Five Year Plan and beyond, taking into consideration: (a) the needs of Government based health care programmes; (b) the requirement of doctors in the private sector; (c) the needs arising from bi-lateral agreements, international commitments and Technical Co-operation among Developing Countries; and (d) necessity to redress regional imbalances in the distribution of medical manpower. 6. The Committee may also consider and make its recommendations in regard to any other related matter. 7. In formulating its recommendations, the Committee may keep in view the reports made in recent years by the various Committee and Conferences on Medical Education. 8. The Committee will submit its report within 6 months.

9. The expenditure on TA|DA of official Members will be met from the same source from- which their pay and allowances are drawn. The expenditure on TA|DA of Non-Official Members will be met from the Sub-head A.l—Secretariat. A. 1(1)— Department of Health A. 1(1) (3)—Travel Ex-penses under Major Head '276' in Demand No. 44 Ministry of Health and Family Welfare for the year 1981-82.

Sd/- (C.V.S. MANI) Additional Secretary to the Govt, of India.

ORDER Ordered that a copy of the Resolution be communicated to the persons named in para three of the above Resolution. Ordered also that the Resolution be published in the Gazette of India Extraordinary for general information.

Sd (C.V.S. MANI)

Additional Secretary to the Govt of India.

ANNEXURE II

Details of Meetings held by the Committee | Subcommittees. I. Medical Education Review Committee

(1) 5th October, 1981 (2) 7th November, 1981 (3) 19th December, 1981 (4) 11th February, 1982 (5) 15th March, 1982 (6) 29th April, 1982 (7) 26th June, 1982 (8) 31st July, 1982 (9) 3rd September, 1982

II. Sub-Committee for formulating Questionnaire 1. 5th December, 1981. III. Sub-Committee on Medical and Para-Medical Manpower Assessment.

(1) 1st March, 1982 (2) 3rd April, 1982 (3) 17th July, 1982.

IV. Sub-Committee on curriculum changes, institutional goals etc.

(1) 12th April, 1982. (2) 31st May, 1982. (3) 9th July, 1982.

ANNEXURE III

Questionnaire issued by the Medical Education Review Committee 1. Undergraduate Medical Education The existing provisions of Medical Council of India with regard to the duration of undergraduate medical education are reproduced below:- III. Duration of Course: (1) Every student shall undergo a period of certified study extending over 4-1/2 academic years from the date of commencement of his study for the subjects comprising the medical curriculum to the date of completion of examination followed by one year's compulsory rotating internship. (2) The first 18 months shall be occupied in the study of the Phase I (Pre-clinical subjects) and introduction to a broader understanding of the perspectives of medical education leading to delivery of health care and no student shall be permitted to join the Phase 11 (Para-clinical|clinical) Group of subjects until he has passed in all Phase I (Pre-clinical) subjects for which he will be permitted not more than four chances (actual examination), provided that four chances are completed in 3 years. (3) After passing pre-clinical subjects, 3 years shall be devoted to clinical subjects and para-clinical subjects concurrently. During the first 18 months of tins period, para-clinical subjects will be taught with the clinical subjects, collaterally and concurrently". Kindly go through the above and give us the benefit of your views on the questions listed below. It is suggested that while filling up the proforma the reflection of the opinions of all the members of the Faculty be incorporated. (a) Do you agree that the duration of undergraduate medical education should be 4-l|2 academic years? Yes No (b) If no, what is the duration you consider most appropriate? (c) Do you agree to the division of 4-112 years of study into 18th months of Phase I for Pre-clinical studies and 3 years of Phase II for para-clinical and clinical studies as in the Medical Council of India regulations ? Yes No (d) If no, what are your alternative suggestions? Give reasons thereof.

Phase-I Phase-II i years years ii years years Internship According to the regulations of the Medical Council of India, every candidate will be required after passing the final MBBS examination, to undergo compulsory rotating internship to the satisfaction of the University for a period of 12 months so as to be eligible for the award of MBBS degree and full registration.

(i) Much has been said and written about the utility of the internship programme as administered at present. Do you agree that one year of compulsory rotating internship as provided in the MCI regulations is desirable and should continue? (ii) If "no", what are your alternative suggestions ? i. ii. iii (iii) If the answer is "Yes" to the first question, would you agree to provide for a more direct responsibility of the interns in patient care and towards this end, should the intern be made responsible for patient care (for a prescribed number of beds) under the supervision of a Registrar (or his equivalent)? Yes No (a) If no, you may state how exactly the intern may be deployed. (iv) Do you agree that there is need for introducing a structured content in the intern's training programme? Structured content in the intern's training programme ? (Structured content refers to both practical aspect and training aspects). (v) Do you think there should be a formal examination at the end of internship ? If yes, should it be only in practicals or in both theory and practicals. (vi) The Medical Council of India recommends posting in community health work at rural health training centre up-graded primary health centre for a minimum period of six months. Has this recommendation been implemented in your institution ? If no give the reasons therefore. (vii) Do senior faculty members regularly visit your rural practice area for training interns as is prescribed ? If no, give reasons therefore. Post-graduate Medical Education The present regulations of the Medical Council of India with regard to the period of post-graduate training leading to the MD|MS degree are reproduced below :— "The period of training for MD|MS shall be 3 years after Ml registration including one year of house job or equivalent thereof and for Diploma courses, 2 years after full registration including one year of house job. The Council encourages universities or medical institutions to have a longer period of training as the Council recommendations are for minimum requirement. The Council, however, emphasises that thorough and intensive training on a planned programme should be given to the students during all stages of the course etc. etc." (i) Do you agree with this recommendation. Yes. No, (ii) If no, what are your alternative suggestions ? (iii) Which system is being followed in your institution-Houseman, Registrarship or Residency. Which system do you prefer ? Give reasons for your preference.

(iv) (a) Do you think that submitting thesis |dissertation should be essential for post-graduation. (b) If no, give reasons therefore. © If yes, what weightage should be given for good thesis |dissertation in over-all evaluation in post-graduation. (d) whether in your opinion the thesis| dissertation should be submitted after the formal examination but before declaration of final result ? (v) Whether rural medical service should be a prerequisite for admission to post-graduation ? If yes, what should be the period of rural service ? List of personalities to whom the questionnaire was addressed. Deans and Principals: (1) Osmania Medical College, Hyderabad. (2) Gauhati Medical College, Gauhati. (3) Darbhanga Medical College, Darbhanga. (4) Medical College, Rohtak. (5) Medical College, Simla. (6) Government Medical College, Srinagar. (7) St. Johan's Medical College, Bangalore. (8) Government Medical College, Mysore. (9) Medical College, Calicut. (10) M. G. M. Medical College, Indore. (11) Grant Medical College, Bombay. (12) G. S. Medical College, Bombay. (13) Government Medical College, Aurangabad. (14) Regional Medical College, Imphal. (15) Veen Sunder Sai Medical College, Burla, Orissa. (16) Medical College, Amritsar. (17) S. P. Medical College, Bikaner. (18) 18. Thanjavur Medical College, Thanjavur, Tamil Nadu. (19) S. N. Medical College, Agra. (20) B.R.D. Medical College, Gorakhpuf. (21) Institute of Medical Sciences, Varanasi. (22) K. G. Medical College, Lucknow. (23) Calcutta National Medical College, 30, Gorachand Road, Calcutta. (24) North Bengal University Medical College, Sushrut Nagar, Darjeeling. (25) Lady Hardinge Medical College, New Delhi. (26) Goa Medical College, Panaji. (27) Jawaharlal Nehru Institute of Post-graduate Medical Education and Research,

Pondicherry. (28) Post-graduate Institute of Medical Education and Research, Chandigarh. (29) M. P. Shah Medical College, Jam Nagar. (30) M. G. Institute of Medical Sciences, Wardha. (31) Stanley Medical College, Madras. Other eminent Medical Educationists & Scientists. (32) Dr. A. K. Basu, Calcutta. (33) Dr. B. Rama- Murthy, Madras. (34) Dr. K. S. Sanjivi, Madras. (35) Dr. B. K. Anand, New Delhi.

(36) Dr. P. K. Sethi, Jaipur. (37) Dr. Santokh Singh Anand, Chandigarh. (38) Dr. Purulkar, Bombay. (39) Dr. Madhayan Kutty, Trivaidrum. (40) Dr. J. S. Bajaj, New Delhi. . (41) Dr. Leela Ram Kumar, Chandigarh. (42) Dr. R. C. Shah, B. J. Medical College, Ahmedabad. (43) Dr. P. K. Chetri, Calcutta. (44) Dr. K. N. Rao, New Delhi. (45) Dr. A. Venugopal. (46) Dr. P. Narasimha Rao. (47) Dr. T. H. Rindani, Jaslok Hospital, Bombay. (48) Dr. P. N. Mishra, Gandhi Medical College, Hyderabad. (49) Dr. C. Gopalan, Nutrition Foundation of India, New Delhi. Members of Medical Education Review Committee. (50) I. D. Bajaj, D.G.H.S. New Delhi. (51) Dr. L. B. M. Joseph, Director, Christian Medical College, Vellore. (52) Dr. H. D. Tandon, Director, A.I.I.M.S., New Delhi. (53) Prof. V. Ramalingaswami, D. G., I.C.M.R., New Delhi. (54) Dr. P. N. Chhuttani, Retd. Director, Postgraduate Institute of Medical Education and

Research, Chandigarh. (55) Dr. Y. P. Rudrappa, Chairman, Postgraduate Medical Education Committee (M.C.I.),

Bangalore. (56) Dr. O. P. Gupta, Director, Health, Medical Services and Medical Education, Ahmedabad. (57) Dr. B. N. Sinha, President, Medical Council of India, New Delhi. (58) Col. R. D. Ayya'r, Retd. D.G.H.S., Madras. (59) Dr. M. M. Mehta, M. P., New Delhi. (60) Dr. Rameshwar Sharma, Principal, SMS Medical College, Jaipur. (61) Dr. K. N. Udupa, Emeritus Professor, Banaras Hindu University. Varanasi. (62) Dr. P. N. Wahi, Retd. D.G. I.C.M.R.,New Delhi.

ANNEXURE IV

Reports of Previous Committees Referred to by the Medical Education Review Committee Report of the Health Survey and Development Committee—1946 (Bhore Committee). Report of the Health Survey and Planning Committee—1961 (A. L. Mudaliar Committee). Report of the Medical Education Committee—1969. Report of the Committee to examine the feasibility of introduction of a scheme of resident service-cum-training in the Hospitals in Delhi—1974 (Shri Kartar Singh Committee). Report of the Group on Medical Education and Support Manpower—1975 (Dr.Shrivastava Committee).

ANNEXURE V

An Approach to the Implementation of the Recommendations of the Committee We have to take an overall view of the medical care in the country in which we will have to fit the medical education part. After all medical education is not an end in itself. It is only a means to an end viz., provision of good medical care to all the population. Viewed in this way the problem can be split into the following parts and our Committee should concern itself to find the answers:

1. Under-graduate medical education. 2. Post-graduate medical education. 3. Minimising the brain drain i.e., finding useful employment for medical men in India. 4. Fitting item 3 in the provision of medical care. 5. Provision of the Infra-structure for item 4—drugs, and x-ray films and equipment in-

cludes electric and electronic. 6. Standardisation of medical care and training on an All India basis and their super-

vision. Under-graduate Medical Education: What are the reasons for modifying the training of doctors in our country? What are our priorities in medical care? In my discussion I will emphasise more on the Rural aspect of the requirements because it was to lack of this in the Rural areas that prompted the formation of the Committee. I also want to emphasise that our medical education should orient itself essentially towards cura-tive medicine. If a doctor can do this reasonably well we should be thankful. If you expect him to look after acute illness, educate the public on health matters &nd supervise water supply, sanita-tion etc., you are asking for the impossible. Before we decide on the number of yours a student must spend in under-graduate education and working out a syllabus, let us take note of the medical needs of the Rural population. This will give us the direction in shaping the syllabus and the period of education necessary; 1. The most neglected segment of the Rural Community is the pregnant female. There is little or no provision for safe delivery. Apart from some of the older medical colleges, the training of male graduate students in midwifery is perfunct. Even the I.M.C. requirement is 10 normal cases and assistance at least 10 other cases. The training in midwifery in most college hospitals is imaginery. In one of the Colleges, the male students sit in an adjoining room to the Labour Room and the Lady Doctor comes and talks to them how the labour was conducted. You will agree that while midwifery in an institutional set up can be done by Lady Doctors domiciliary midwifery involving travel at night alone to lonely places has to depend heavily on male doctors and that without adequate training in midwifery, Rural midwifery will continue to be primitive. I also feel that it is this lack of adequate training in midwifery that is one of the major causes of the male doctor staying away from going to rural areas. On the other hand practice in urban set up creates no such handicap, as midwifery is essentially institutional. 2. Then take the commonest cause of child mortality—acute gastro-enteritic—unless a doctor is able to put a needle into the child's vein and give the correct quantity and quality of fluids intravenously the mortality will be heavy. And yet today you cannot find a young graduate, who has not actually worked for some time in an acute Paediatric ward, able to put a needle into

the veins of a 3 months' old baby let alone in a dehydrated baby. The following is an actual recent incident only for your information: In an area where one of the common causes of meningitis is complication of spinal anaesthesia (iii) a patient of iatrogenie meningitis was transferred to a referral hospital in bad shape. The sister having failed to insert an intravenous needle (this was an adult patient) asked the attending doctor— neurologist—to do a cut down. The answer was "Sister, if I could do a cut down I would have been a neuro-surgeon and not a neurologist." The recent happening in Kerala where about 50 children with fever, headache and vomiting died of meningitis without a diagnostic lumber puncture should make us ashamed. If the child mortality goes unchecked family planning programme will be a fiasco 3. The Rural population is entitled to proper treatment of acute illness in its own area. Therefore, the graduate should be competent in the diagnosis of all acute conditions and be able to treat acute medical and paediatric conditions and diagnose surgical conditions. 4. In the Rural set up the doctor will have to depend on himself for all his laboratory examina-tions and to do a blood transfusion, If we accept the above premises the skeleton or the frame-work of under-graduate syllabus takes shape and will include - 1. Excellent familiarity with clinical side room work viz., Blood for total and different cal count—abnormal WB cells—Hb. Hot. RBCBSR Malarial Parasite—urine reaction—Sp or Albumin— Sugar, ketone bodies and microscopic examination of deposit—bile salts—urinary chlorides—Urinary diastase. C S F Cell count and grams stain and Acidfast pus ordinary, gram stain and Acidfast stain. This will mean working 6 months in a large clinical side room for 2 hrs daily from 8 to 10 A.M. 2. Four months in midwifery—7. a.m. to 7 p.m. and 7 p.m. to 7 a.m. in two batches, number in each batch depending on number of admissions. 3. One year acute ward—All acute medical and surgical patients are admitted to a common ward-— a 3rd year, 4th year and final year students team up and take the history, examine the patient completely,—that is, even an acute appendicities patient will have his nervous system including optic funds, Respiratory, Cardiac system etc. fully examined— do the necessary investigation like urine, blood, C SF after lumber puncture (when necessary) ECG and X-ray. A diagnosis is established which is confirmed by the Clinical Teacher present in the Ward and the treatment initiated and continued by the team under the guidance of the Teacher. One year of this training 12 hours daily should make any graduate a good doctor. 4. Matching and grouping of blood and giving at least 20 blood transfusions during the period of training. 5. Work in the hospital bio-chemistry and Microbiological to familiarise with routine bio-chemical investigation and know the appropriate culture media in addition to the routine hospital practical work.

Most of teaching should be clinical and clinico-pathological sessions with hardly any or very little didactic lecturing. Pre-Clinical The separation of medical education into watertight compartments seems to me to be made more for the convenience of teachers than for good medical education. Take two instances : The AIIMS has or at least had excellent preclinical teaching. The students were hand-picked And yet in the 3rd year—the 1st year of clinical studies—when shown a patient with wrist drop and asked for the nerve which supplied the paralysed muscles, there was no answer. The fault was certainly not with the students. Over the last 20 years and more, I have asked under-graduate and post-graduate candidates what was the quantity of secretion in 24 hours of saliva*, gastric juice, pancreatic juice, bile and succis Entericus and their composition. I still have not had a satisfactory answer. And still to treat acute Gastro-enteritis chronic pyloric obstruction and acute intestinal obstruction, the knowledge is essential. I want to suggest the study of anatomy be confined to lecture demonstrations on dissected specimen of that anatomy which a general medical practitioner should know thoroughly. This should mainly be anatomy applied to medicine and surgery coming under the purview of general practitioner. Similarly in teaching physiology the emphasis should not be knowing bare facts but on applied physiology. The further teaching of both applied anatomy and physiology should be conducted in ch'mcal classes where the anatomist, phvsioloeist pathologist, micro-biologist, bio-chemist and clinician will collaborate. From the above, as a frame-work, an undergraduate curricula can be constructed after consul-tations with the various departments. It will be noted that I have made no mention of pharmacology. I feel applied therapeutics should be taught in the wards by clinicians and clinical pharmacologist and not in the college laboratories. The new drugs come on the scene with alarming rapidity, replacing the older ones so that in 5 years time very few of the older ones remain in use. The time spent on lecture and demonstration on animal experimental pharmacology could well be replaced by clinical pharmacologyin-the ward on human patients. Jurisprudence should not form part of the syllabus. Doctors taking a Government job can be given a course on appointment. It must be made compulsory, that every student possesses along with stethoscope, a tendon hammer, a torch and an opthalmoscope. Students be encouraged to examine the funds of all patients whom they examine. They should be familiar with funds appearance of hypertensive and diabetic retinitis and papillocdeme of intracranial hypertension. I feel all graduates should know how to lake intra-ocular tension because glaucoma is far more common than people imagine. I remember years ago my opthalmic colleague at Safdarjung insisted on all cases of headache coming to the Emergency Ward being examined by an

Ophthalmologist. The result was detecting an average of seven patients of acute glaucoma a week. So if we really mean to prevent blindness one should include ability to measurement of intra-ocular tension in the undergraduate syllabus. One of the major changes that will have to be effected is transferring the Bio-Chemistry and Micro-biology Departments from the College to the hospital buildings where they will function on a 24-hour basis like clinical Departments. As for pathology only general pathology need be taught in the Department. Pathology as related to diseases should be done along with clinical medicine and in the autopsy room. There should be an earnest attempt to introduce the Bombay Coroners Act throughout the country so that autopsies are done routinely. With autopsy we will be a major, medical power in the world; otherwise we will continue to be what we are. As for histopathology even when specialists differ in their interpretation it will be ridiculous to examine the under-graduates in histopathology. Post-Graduate Medical Education (Clinical Subjects): Again the object is to train a graduate doctor to be good practical specialist; For this a continuous period of 3 years practical and clinical training is essential. It is presumed that the institution has adequate clinical material, has a good library, the laboratory and radiological facilities are above reproach end adequate and additional facilities like dialysis, nuclear medicine investigation are all available. In addition there should be teacher clinicians who should be prepared to spend considerable periods of time with the post-graduates in the wards. My idea is that a teaching unit should consist of 2 teachers, say a professor and Associate or Assistant Professor each being in independent clinical charge of 30 beds but collaborating in teaching and also giving consultant cover in the absence of the other. The Post-graduate in his 1st year is posted as Junior Registrar to the Associate Professor's beds. In the 2nd Year he passes his Postgraduate examination. The 3rd Year is spent as Senior Registrar to the whole unit working under both the teachers. As there will be no Assistant Professor or Lecturer, the clinical and operative experience obtained during the 3-year period under two different teachers will be adequate for proper training. At the end of the 3rd year training he should be able to practise as a Specialist independently. There is no necessity for a thesis or any other substitute for thesis. The training is essentially cli-nical and practical and there is no time to waste on writing a- thesis, which, in most cases, is not worth the paper on which it is written. I do not think any syllabus need be laid down. The clinical teachers should have the responsibility of training their charge to become a competent practising specialist. The methods may be left to them. By finding useful and gainful employment for doctors brain drain can be minimised and medical care provided to all people. As soon as a doctor graduates, he is offered the following facilities for group practice in a rural area: 1. For a group of four doctors funds for building a Poly-clinic building with residential accommodation for the doctors will be arranged with a bank at a low rate of interest. 2. Funds for buying the equipment necessary for a general practice—also should be arranged. The

information regarding cost and source are also given. It is estimated that for a population of 1,00,000, there will be an amiual consultation of 4.00,000. This with domiciliary midwifery and treatment of illness should guarantee a very satisfactory financial income. For providing hospital medical care and employment for the post-graduate, it is recommended that all P.H.Cs be converted into 60 bedded hospital capable of expansion into 100 beds at a future date. Each hospital should have a Physician. Surgeon, Anaesthetist and an Obstetrician, a 100 MA X-Ray Unit and adequate Bio-chemistry and Microbiology Laboratory support for diagnosis of all acute illness. The four general practitioners can also be employed on a part-time basis to help the hospital doctors so that their medical knowledge is kept reasonably up-to-date. The hospital will also have residential accommodation for the Doctors and other para medical personnel who are not local people. For a 60 bedded hospital the average annual intake would be more than 3,000 admissions and this should keep the 2 Specialists busy and with a wide variety of patients for their professional interest would be kept up. Para Medical Personnel The one way to-improve radically the standard of medical care would be to upgrade the standard of professional knowledge of the para-medical personnel like Radiographer, Laboratory Techni-cians. The ideal solution would be to have the syllabus of hospital laboratory technicians and Radiographer course of U.K. adopted as a standard one. J he hospital and Radiology units m for training should be accreditated. This laboratory and Radiological support for the Rural hospitals would be a beneficial factor in improving the quality of clinical work. No health care can survive without adequate supply of drugs of quality. The quantity of course would be enormous. Drugs are— 1. 100-150 Essential Drugs.—(WHO has delineated them, with modifications to suit our country's requirement, the list can be accepted as our Essential Drug List.) The Kerala Government constituted a Kerala Drug and Pharmaceutical Limited Company to produce or formulate and supply all Essential Medical Items to the 200 and odd medical institutions of that State. This was to be on no-loss-no-profit basis and when this was done they could supply drugs at l/3rd the cost at which they were buying in bulk supplies. The items included I.V. Fluid like glucose, glucose saline etc. in addition to the Essential Drugs. It should be possible for all States to start 2, 3 or more such factories depending on the size of the State and make possible, availability of all Essential Drugs and I.V. Fluid for all their State Medical Institutions down to Rural Hospitals at considerably cheaper rates than at present. The availability of medicines at hospitals is a grant morale booster for the population and doctors. 2. Other Drugs.—To obtain these at cheaper rates than at present, I suggest that the Centre, Railways, Defence and all States and Public Sector Undertakings declare their requirements for the succeeding year and a Committee consumed by the Centre enter into a running rate contract with pharmaceutical firm whose products have been certified by the Drug Controller as of required standard and purity.

Once this is done the individual Units will, on the basis of the original demand, get on 1st January 2 months' supply and on the 1st of the succeeding months one month's supply. This will ensure staggering of production by firms, saving of medical storage space in hospitals and of course pilferage which is bound to happen when large quantities of medicines are stored. Further, this will avoid maintenance of an utterly useless and wasteful medical stores department and deposits, (except in the Defence Services where supplies have to be stored and kept in readiness against emergencies), The responsibility of the Centre would be to ensure regular supplies of high quality drugs and the States to ensure a- prompt payment on receipt of the supplies. 3. Equipment, Surgical, Medical, Electrical and Electronic.—The responsibility for the ready availability of a standard pattern of all necessary equipment as laid down by an Expert Panel appointed by Government, should be that of the Central government in collaboration with the States. If import of equipment is necessary this should be of a common pattern and arrangements for repair and spare parts should be full proof. 4. Hospitals.—The first requirement for teaching clinical medicine is adequate clinical material—not too much or too little. Today for the considerably increased annual intake of medical students the inpatient material is insufficient and the out-patient one too much for orderly teaching. Our object can be achieved by converting all Government hospitals including District Hospitals into Associate Teaching Hospitals. Apart from providing an almost clinical material for practical teaching, the upgrading in equipment, laboratory facilities and staff and buildings which will accompany the upgrading will benefit the district and Rural population thus achieving the double object of improving medical care and medical education. I further suggest that all teaching hospitals be supplied with standard equipment- Laboratories—Radiological, Electrical, Electronic, hospital furniture, Operating Theatre, nuclear medicine, etc. on a formula adopted from the one use in Defence Medical Supply. The provision of all necessary equipment, drugs, X-ray Film etc. on a standard basis will go a long way in removing the gross disparities in the quality of medical care and medical education in the country. 5. Standardisation of Medical Education— It seems to be only a matter of time before we have medical degrees in the different regional languages losing what little communication we have between the different medical centres. Before this happens, I think the Centre should step in and take over temporarily" say for 10-15 years the responsibility for medical education. The hospitals in the State are mainly State-owned but I do not see any great difficulty in the Centre coming to a mutual understanding with the States on the use of hospitals for Medical Education in public interest. The responsibility should function through a Central Medical University with Regional Bran-ches—North, South, East, West and Central. This seems |o be the only method to improve the quality of, medical education on all India basis, while the Central University will have 1/5th representation from each Region. Each Regional Branch will be administered in a similar way i.e. l/5th representation for each Region, e.g., South Region will be administered by a Group consisting of 1/5th from North, l/5th from South, l/5th from East, l/5th from West and l/5th from Central Region. This will eliminate pressure from local groups, the bane of Medical Education in many States. 6. Rural Health Board—To ensure quick results in the upgrading of P H C to 60 bedded hospitals, a Rural Health Board will have to be constituted. They will ascertain priorities in location arrange for building and equipment and staff and monitor progress. If all the 5.500 P H Cs can be

converted into 60 bedded hospitals within a space of 10 years, we would have achieved something which the planners of 1st Plan would never have thought possible. If the principles enunciated above are accepted, details can be worked out in a short time. If my views find general acceptance, it should be possible to draft the syllabi for under and post medical graduates modern in concept, content in depth, practical in implementation and above all beneficial to the vast Rural Population, as well as Urban people.

Sd/

Col. R. D. Ayyar.

Report of the Medical Education Review Committee

Part II

Medical Education Review Committee* CHAIRMAN Dr. Shantilal. J. Mehta MEMBERS

(1) Col. R. D. Ayyar (2) Dr. I D. Bajaj (3) Dr. P. N. Chhuttani (4) Dr. O. P. Gupta (5) Dr. L. B. M. Joseph (6) Dr. M. M. Mehta (7) Prof. V. Ramalingaswami (8) Dr. Rameshwar Sharma (9) Dr. Y. P. Rudrappa (10) Dr. B. N. Sinha (11) Prof. H. D. Tandon (12) Dr. K. N. Udupa (13) Dr. P. N. Wahi

MEMBER-SECRETARY Shri N. N. Vohra (from inception uptill 4th October, 1982) Shri P. P. Chauhan (from 8th November, 1982) The committee was established Vide Government of India Resolution dated the 8th September, 1981. It commenced functioning on 5th October, 1981, and submitted its Report (Part I) on 12th October, 1982. The final meeting of the Committee was held on the 10th December, 1982.

STAFF OF THE COMMITTEE Shri R. Srinivasan—Research Officer Shri J. C. Hand a—Private Secretary to Chairman. Shri A. V. L. Narasihga Rao—Sr. P.A. to Member-Secretary Shri K. K. Mehta—Research Assistant Shri H. L, Dhamija—Research Assistant Shri M. S. Chavvla—Stenographer Shri Pritpal Singh—L.D.C. Shri Kundan Singh—Messenger

REPORT OF THE MEDICAL EDUCATION REVIEW COMMITTEE PART II

1. The Medical Education Review Committee submitted to the Government, on 12th October,1982, the first part of its Report on all its terms of reference except the one relating to medical manpower assessment. It had earlier been agreed that the Committee would separately submit, in Part II of the report, its recommendations on the below stated term of reference :—

"This Committee will also evolve realistic projections of medical manpower requirements (MBBS doctors, general specialists and super-specialists) during the Sixth Five Year Plan and beyond taking into consideration : (a) the need of Government based health care programmes ; (b) the requirements of doctors in private sector ; © the need arising from bilateral agreements, international commitments and Technical Cooperation among Developing countries; and (d) Necessity to redress regional imbalances in the distribution of medical man power." 2. At its meeting held on 19th December, 1981 the Committee appointed a Sub-Committee to examine the issues contained in the term of reference quoted in para 1. The Committee felt that manpower assessment should not be restricted merely to "doctors but should also take into account the various categories of para-medical personnel. The Sub-Committee was accordingly assigned the task. The Sub-Committee's report was circulated to all members of the Committee on 25th October, 1982. In the interest of speedy fmalisation of Part II of the Report, the Members of the Committee were requested to send their comments on the Report of the Sub-Committee. Such comments as were received have been taken into account while finalising the Report. After due consideration the Committee agrees with the recommendation of the Sub-Committee, as contained in the later's report in the pages following. 3. The Committee observes that due to dearth of relevant statistical data, it is not possible to evolve reliable assessment of the existing stock of medical and health personnel and, consequently, to make any recommendations regarding an in crease decrease in the existing scale of production of functionaries of various categories. 3.1 The Committee hopes that Government would give very early thought to the recommendations contained in the Sub-Committee's report. 4. The Committee wishes to place on record its appreciation of the services rendered by Shri N. N. Vohra, formerly Joint Secretary in the Ministry of Health and Family Welfare, who functioned as the Convenor of the Sub-Committee and assisted in preparing its draft Report even after relinquishing office as Member-Secretary of the Committee. The Committee also would like to place on record its grateful thanks to the Members of the Sub-Committee for the very keen interest evinced by them.

Sd/- R. D. AYYAR

I. D. BAJAJ P. N. CHHUTTANI

O. P. GUPTA L.B. M. JOSEPH

M.M. MEHTA V. RAMALINGASWAMI

RAMESHWAR SHARMA Y. P. RUDRAPPA

B. N. SINHA H. D. TANDON

K. N. UDUPA P. N. WAHI

P. P. CHAUHAN S. J. MEHTA

REPORT OF THE SUB COMMITTEE ON MEDICAL AND PARA-MEDICAL MANPOWER REQUIREMENTS

1. At its meeting held on 19th December, 1981 the Medical Education Review Committee appointed a Sub-Committee to examine the issues contained in para 3 of the Committee's terms of reference, viz :— "This Committee will also evolve realistic projections of medical manpower requirements (MBBS doctors, general specialists and super-specialists) during the Sixth Five Year Plan and beyond taking into consideration :.-— (a) the need of Government based health care programmes ; (b) the requirements of doctors in private sector; © the need arising from bilateral agreements, international commitments and Technical Cooperation among Developing countries : and (d) necessity to redress regional imbalances in the distribution of medical manpower". The Sub-Committee was asked to submit an early report to the committee. 1.1 The Sub-Committee consisted of : — 1. Dr. P. C. Bhatla,

Dean, IMA College of General Practitioners, New Delhi. 2. Prof. Gautam Mathur, Director,

(Shri A. K. Dasgupta, Adviser— Alternate Member). Institute of Applied Manpower Research. Indraprastha Estate, New Delhi.

3. Dr. O. P. Gupta, Director of Health, Medical Services and Medical Education, New Civil Hospital, Ahmedabad.

4. Dr. P. S. Jain, Secretary, Medical Council of India, New Delhi.

5. Prof. Usha K. Luthra, Senior Deputy Director General, Indian Council of Medical Research, New Delhi.

6. Shri K. Ramachandran, Associate Professor and Head, Biostatistics Division, All India Institute of Medical Sciences, New Delhi.

7. Dr. Rameshwar Sharma, Principal, S.M.S. Medical College, Jaipur.

8. Dr. H. D. Tandon, Director, All India Institute of Medical Sciences, New Delhi.

9. Shri M. C. Verma, Joint Adviser; Manpower Unit, Planning Commission, New Delhi.

10. Shri N. N. Vohra, Convenor Joint Secretary, Ministry of Health and Family Welfare, New Delhi.

Procedure adopted 1.2 The Sub-Committee held three meetings (on 1st March, 1982, 3rd April, 1982 and 17th July, 1982) to consider the issues referred to it. 2. At its first meeting, the Sub-Committee decided to collect all available information regarding

admissions|output of the graduate|post-graduate courses for the years 1980 and 1981 is well as about the existing stock of medical and paramedical, personnel, all over the country. Accordingly communications were addressed to the various concerned quarters, governmental and non-governmental, seeking the requisite information in regard to the various categories of health personnel. The statement at Appendix I indicates the details of the organisations addressed and the results achieved. 2.1 The responses received from the various organisations which were addressed have been unsatisfactory, despite repeated reminders. Consequently, the Sub-Committee could not meet as often as originally envisaged, to complete the task assigned to it. Analysis of the obtaining situation 3. The Sub-Committee is dismayed at the patent inadequacy of the readily available information in regard to the eixsting stock of health personnel in the country. It is also to be observed that the assessments of health manpower requirements, undertaken so far are rather sketchy, being based on incomplete data. Even these projections have not been up-dated and are, as today, of Limited worth. 3.1 The Institute of Applied Manpower Research, New Delhi (IAMR) had undertaken in 1966, 1970, 1971, 1977 and 1979 health manpower studies relating to different categories of health personnel. As no special facilities exist in the IAMR for continuing such work on a sustained basis it has not been able to up-date its researches to continually evolve the kind of projections which are so vital to appropriate decision making regarding health manpower developments}. 3.2 The Ministry of Health and Family Welfare and the Institute for Research in Medical Sta-tistics, New Delhi (an establishment of the ICMR) are also not possessed of the requisite infrastructure for undertaking health manpower studies. 3.3 The Planning Commission has been engaging itself in health manpower analysis at the time of formulation of sucessive Five Year Plans. For want of to-date information regarding available stocks of health manpower the Commission's projections regard to future requirements have, per-force, been built upon rather broad-based assumptions. 3.4 The Sub-Committee has been disheartened to note that the various statutory bodies respon-sible for the primary registration of medical professional—Medical Council of India, Central Councils for the various Indigenous Systems of Medicine and Homoepathy, Dental Council, Pharmacy Council etc.—have not been able to keep their registers up-to-date. The information available with these bodies represents one time registration of the practitioners. Since there is no system of renewal of registration a good number of those registered may have since ceased to be in practice, migrated from the country, expired etc. Consequently, persons listed on the Central Registers are not those actually engaged in practice in the various States |UTs. 3.5 The Sub-Committee noted that there are a very large number of semi-qualified|unqualified practitioners of various systems of medicine who are not registered with any governmental agency. The information supplied by the Private Medical Practitioners' Association of India and the All India Private Medical Practitioners' Association, who were approached in the matter, may be seen in the statement at Appendix II. Prima facie, the information is incomplete in regard to distribution as per the various systems of medicine, State}UT wise dispersal, percentage break-up as per levels of education and professional training (if any) of the practitioners etc.

4. Through persistent efforts, the Sub-Committee has been able, by tapping all possible sources, to collect data in regard to the admissions|output in regard to graduate, post-graduate (diploma and degree) and post-doctoral courses. This may be seen in the statement at Appendices III and IV. The information is incomplete, as a good number of institutions failed to respond to the communications from the Sub-Committee or furnished only partial information. 4.1 A number of new medical colleges have been established in the recent past. It is not known whether these institutions shall, in due course, be able to secure the recognition of the Medical Council of India. If they manage to do so, their future product shall also require to be duly taken into account, for computing the net annual out-turn of graduates, post-graduates etc. 5. Besides addressing the medical colleges, Professional Councils, State Governments etc., the Sub-Committee considered it necessary to secure in formation regarding the manpower requirements for the implementation of the major national health programmes e.g. those relating to Malaria, TB, Blindness, Leprosy, Family Planning etc. Besides, it was also considered worthwhile to address the larger public sector employers e.g. the Ministries of Railways, Defence, Labour, Posts and Telegraphs and ascertain their existing stock of personnel and requirements for the future. The information which became available uptill 30th September, 1982 in regard to major health programmes may be seen in the statement at Appendix V. It is incomplete and, consequently, not amenable to any meaningful analysis. 5.1 The response from the Central public sector undertakings, reflected in the statement at Appendix VI has been comparatively more satisfying. However, this information is not complete and requires further refinement. 5.2 Efforts were also made to evolve as reliable a picture as possible regarding the requirements of the private sector. In this connection, the Federation of the Indian Chambers of Commerce and Industry was addressed. The Federation was very helpful and assisted in the supply of information in regard to 33 Companies, which is contained in the Statement at Appendix V. 5.3 At the Sub-Committee’s request, the Voluntary Health Association of India supplied useful information in regard to the personnel employed in private hospitals and clinics, which is contained in the statement at Appendix VII. 5.4 The State Governments and Union Territory Administrations were addressed to elicit information regarding the available stock of manpower comprising self-employed practitioners. Their response has been inadequate. Consequently, the data which has become available is of restricted value. The Indian Medical Association have also not been in a position to supply information regarding the existing stock of private registered practitioners (generalists and specialists). 6. The various concerned Departments of the Government of India—Ministry of External Affairs, Foreign Assignment Section of the Ministry of Home Affairs, Department of Science and Tech-nology (Indians Abroad Register) etc.—were addressed to gather together reliable information in regard to the number of medical personnel who have been leaving the country, in recent years, to secure higher qualification, specialised training or for employment. Full information in this regard has not become available from any quarter. Non-availability of norms 7. In the process of its deliberations, the Sub- Committee noted that as regards the

assessment of manpower requirements for the future there do not exist, at present, any nationally accepted norms in regard to : - population : doctor ; - population : dentist ; - doctor : nurses ; - population : specialist (speciality-wise) - population : super-specialist (super-speciality-wise) ; - doctor : pharmacist ; - doctor : para-medics (various categories) ; - population : hospital-beds ; - doctor: hospital-beds ; etc. 7.1 It is obvious that projections regarding the requirements of manpower of various categories|grades of skill cannot be undertaken without establishing the crucial ratios referred to in para 7. Consequently, it is not possible to work out the number of educational and training institutions required, all over the country, to "produce the number of health personnel, of various grades of skill, required for meeting the present and future health care needs of the country. 8. As regards the development of the health infrastructure to achieve the goal of Health for All by the year 2000 A.D., the Sub-Committee observed that a Working Group established by the Mini-stry of Health and Family Welfare, to evolve Sixth Plan proposals for the Health sector, had worked out the basis|norms for the establishment of Sub-centres, subsidiary Health Centres, Primary Health Centres, Community Health Centres etc. covering the period uptill 2000 A. D. On the basis of the approach established by the Working Group the number of the various categories of health personnel was also worked out. Subsequently, taking into view the recommendations of this Working Group, the Planning Commission have laid down physical targets for infrastructural development during the VI Plan and also given a broad indication of the required pace of such growth till 2000 A.D. 8.1 In the aforestated context it is to be further observed that while the VI Plan document provides the parameters for the development of the governmental health services infrastructure, from the sub-centres upto the Community Health Centre level, nationally accepted norms in regard to the establishment of dispensaries, hospitals, centres for specialised treatment etc. arc not available. Furthermore, in so far as health manpower planning is concerned, a State-wise picture regarding the percentage of the population envisaged to be served through the governmental sendees has still to be evolved. Unless such ratios, worked out on a well considered, practical, basis are available, it is not possible to undertake manpower assessment on a centralised basis. 8.2 The Sub-Committee also observed that in moving towards a complete assessment of available health manpower in the country due notice would naturally have to be taken of the very large number of practitioners of the various Indigenous Systems of Medicine and Homoeopathy whether they are registered or unregistered, qualified or unqualified. The existence of such practitioners as well as of those of the modern system of medicine who are unqualified yet active in practice is a fact of life and cannot, therefore; be ignored. 8.3 Once the requisite information regarding the available stock of health personnel is available, on a reliable basis, it would be possible to evolve projections regarding present and future manpower requirements. The working out of requirements for the future would naturally have to take into consideration the erosion of the existing stock on account of superannuations, migrations, change in vocation etc. Standard ratios for each of these factors would therefore require to be worked out.

Recommendations 9. Keeping in view the discussions in paras 3—8 above, the Sub-Committee makes the recommendations set out in paras below, for the consideration of the Medical Education Review Committee. National Health Manpower Policy 9.1 A relevant National Health Manpower Policy can be evolved only within the parameters of the National Medical and Health Education Policy. Needless to say, the latter Policy can flow only from the National Health Policy. The Ministry of Health and Family Welfare have only recently finalised the National Health Policy. It, therefore, appears necessary that further work on the National Health Manpower Policy should commence only after the National Medical and Health Education Policy has been finalised, clearly bringing out the kind of medical and health personnel, of identified categories, required to be produced, for meeting the present and future health care needs of the country. 9.2 The National Health Manpower Policy would naturally need to take into account and evolve a fully integrated view regarding the utilisation of practitioners of all systems of medicine and not merely those of the Allopathic system. National Medical Manpower Census 9.3 While it would take some time for the National Medical and Health Education Policy to be finalised it is necessary to initiate action, on a time bound basis, to arrive at a reliable assessment of the available stock of health manpower, encompassing health functionaries of all kinds, belonging to the various systems of medicine, actually active in practice. Considering the vastness of the country and the coverage of the presently available registration systems, the Sub-Committee is of the considered view that the objective can be achieved only through a nation-wide Medical Manpower Census, to be conducted during a fixed period (say a week) after organizing effective publicity throughout the country. It may be necessary to publicise that those who are not registered during the Census Operations would not be eligible to practise and may have to face legal consequences, as may be prescribed. The proposed Census would enable the States to identify the exact numbers of qualified practitioners, of the various systems of medicine, against whose functioning there has been mounting criticism in the recent past. The Indian Council of Medical Research (Institute for Research in Medical Statistics), National Sample Survey Organisation, Institute of Applied Manpower Research and Planning Commission may be consulted in finalising the list of items in respect of which information requires to be collected as well as for evolving parameters of the proposed Census Manpower assessment during interim period 9.4 As the proposed Medical Manpower Census would naturally take some time to be organised, if it is decided to hold it, it is felt that the following measures may be taken on an immediate basis: (i) The Ministry of Health and Family Welfare may address ail State Governments and Union Territory Administrations to undertake a reliable district-wise assessment of available health manpower of various categories and systems of medicine. Perhaps the Planning Commission can be persuaded to address the State/ UTs in the matter. It is unavoidably essential that at the time of preparation of every Five Year Plan, the States and Union Territories should furnish a reliable

assessment of the stock of medical and para-medical manpower as it stands at the close of the on-going plan, requirements upto the close of the succeeding Plan (annually) and projections for the next succeeding Plan. In this context the States and UTs must specifically state their objectives and the nature of help they would require from the Centre. Furthermore, those responsible for the implementation of the various national health Programmes should intimate the stock and projections in regard to technical personnel required in respect of such programmes. It is felt that if the States/ UTs accept this obligation and undertake to discharge it on an organised basis it should be possible for them to collect and compile the requisite information within 3 months. The format for eliciting the necessary information may be evolved with the assistance of the I AMR, New Delhi and finalised in consultation with the NSSO/Planning Commission, To ensure speedy results, the Ministry of Health and Family Welfare may have the reporting forms printed on a centralised basis. In case financial problems arise perhaps available extra-budgetary sources could be utilised for the purpose. Up-to-date Registration of Health Personnel (ii) The Ministry of Health and Family Welfare may issue a suitable directive to the Central Councils of the various systems of Medicine, Dentistry, Pharmacy, Nursing etc. to advertise and call upon all qualified personnel to register/renew their registration with the concerned Councils within 4/5 weeks. Towards this end, each of the various Councils may make available, on request, self-addressed reply cards on a well-considered format, listing the items in respect of which information is sought. Inter-alia, the information to be collected must include the qualifications of the practitioner, when and from where obtained; age; sex; whether practising as a generalist/specialist/ super-specialist; whether self-employed or working for State/Central Government or public sector organisation, local bodies, private organisation etc; whether functioning in urban|rural areas; etc., etc. (iii) In the efforts as at (i) and (ii) above, the cooperation and assistance of the Indian Medical Association, various specialists' Associations, similar bodies of the various other systems of medicine and the Voluntary - Health Association may also be solicited. (iv) The Ministry of Health and Family Welfare may hold consultations with the various Associations of Private Practitioners and persuade them to launch special drives to enlist and prepare to-date registers of all unqualified practitioners (it is assumed that the qualified candidates would get registered with the concerned Central Councils), indicating their age, sex, levels of education and training, whether practising in the urban/rural areas etc. If necessary, suitable financial support may be made available to identified bodies/agencies to secure the desired results. Categories of health personnel to be assessed 10. While the proposed National Medical Manpower Census may enlist and prepare to-date in-ventories of health personnel of all kinds, engaged in active practice, the short-run assessments proposed in para 9.4 may cover :— (i) General practitioners (of all systems of medicine) ; (ii) Specialists (-do-); (iii) Supper-specialists (-do-); (iv) Dental Surgeons (at various levels of functioning) ; (v) Nursing personnel (including ANMs, LHVs, Midwives, and Public Health Nurses); (vi) Pharmacists; (vii) Laboratory Technicians ; (viii) Physip-therapists|Occupational Therapists ;

(ix) X-Ray Technicians ; (x) Ophthalmic Assistant|Technicians. Fixation of ratios/ norms for health personnel to population etc. 11. It is hoped that the Ministry of Health and Family Welfare would consider and take early decisions regarding the recommendations contained in. para 9 above. Side by side with action on various fronts, to assets the existing stock of health manpower, it would be extremely necessary for the various Central Councils and each of the Specialist's Associations to urgently get involved in exercises to establish uniformly accepted service norms; (doctor—population, dentist-population, etc. ratios referred to in para 7) on the basis of which present and future requirements of health manpower could be worked out. It may be observed that the basis of these norms must necessarily flow from the health care approach engrained in the National Health Policy. It is relevant to reiterate that those norms must be realistic and pragmatic, keeping in view the socio-economic conditions of the country, and not be related to exotic western models of health care. These norms would naturally be variable for the urban and rural areas. Along with the norms, there is need for evolving an agreed view regarding the average period of active work to be expected of practitioners at various levels of functioning, to determine a viable attrition rate. In this context, the Ministry of Health and Family Welfare may consider organising a meeting of experts, involving representatives of the various Central Councils and Specialists Associations of physicians, surgeons, gynaecologists, paeditrictions ophthalmologists etc. etc. The Institute for Research in Medical Statistics (ICMR), NIHFW and the Institute of Applied Manpower Research can be use fully involved in this exercise. It may be pointed out that without formulating some form of normative projections of future requirements of specialists. It would be difficult to relate the admissions to-the various, prost-graduate courses to assessed requirements of specialists, as recommended by the Committee in its Report (Part I). Migration of personnel 12. The National Medical Manpower Policy, to be evolved, must necessarily take into account the migration of physicians, nurses etc. in recent years whether under governmental exchanges or otherwise—and provide, in the overall assessment of requirements, for a given percentage of health personnel, of various categories and grades, to leave the country, every year, for service, higher education and training etc. abroad. Centralised systems and procedures would require to be evolved, in consultation with the various concerned Ministries and agencies, to maintain to-date, accurate records of all such out-flows. Such information is not available at present, from any quarter. Continuous assessment of health manpower 13. Whatever be the approach adopted by the Ministry of Health and Family Welfare in pro-ceeding to arrive at a reliable assessment of the existing stock of health personnel it would be most essential to organise a mechanism to continuously collect, monitor and analyse health man-power date. In this context, perhaps the ideal arrangement would be to ensure the establishment of Health Manpower Bureau in every State and Union Territory, linked with a Central Health Manpower Bureau. If this approach is accepted, the constitution and style of functioning of the proposed Bureaux could be finalised in consultation with the IAMR, NSSO and the Planning Commission. The expenditures on account of the establishmentjfunctioning of the proposed net-work could perhaps be met under a new Centrally Sponsored Plan Scheme or from the extra-budgetary resources of the Ministry of Health and Family Welfare. Survey by National Sample Survey Organisation 13.1 It is understood that the National Sample Survey Organisation have agreed, in their projected work plan, to undertake a survey of Vital Health Statistics. This Survey is likely to be conducted

during January—June, 1984. Keeping in view the larger perspectives it would be useful for the Ministry of Health and Family Welfare to hold a meeting with the representatives of the IAMR, NSSO and the Planning Commission to consider and decide whether it would be possible to include Health Manpower even on a limited basis, as one of the items of the proposed Survey. In any case, it would be beneficial to evolve, in consultation with the aforementioned bodies, a fully integrated and harmonious view regarding immediate and future action in the matter. Needless to say, after arriving at a reliable assessment of the existing stock of medical and health manpower, it would be necessary to evolve projections for future requirements, keeping all relevant factors in view. 14. Whatever the decision of the Ministry of Health and Family Welfare in regard to the re-commendations of the Medical Education Review Committee (based on the report of the Sub-Committee), it appears essential that the efforts made by the Committee's Secreariat are carried forward and the date collected by it is further worked upon and refined. This can be done by creating a small Manpower Planning Cell in the Medical Education Division of the Ministry. In the alternative, the responsibility can be entrusted to the Director, Central Bureau of Health Intelligence of the Institute for Research in Medical Statistics, New Delhi (an establishment of the Indian Council of Medical Research). It would be necessary for the entire records of the Sub-Committee dealing with collection of manpower data to be transferred to the authority designated to handle this rather important item of work. Demand projections in respect of medical and certain para-medical manpower requirements 15. The information collected by the Sub-Committee in regard to certain categories of health per-sonnel, the obtaining training capacities, employment situations etc. has been put together in the statement at Appendix VIII. This as well as all other available information was passed on to the Institute for Research in Medical Statistics (ICMR), New Delhi, for projecting the requirements of medical manpower in the period uptil 2000 A.D. The IRMS have made certain projections relating only to personnel of the modem systems of medicine, viz. doctors, dentists, nurses and pharmacists. In computing existing stocks and assessing future needs the IRMS projections have not taken into account—(i) the practitioners (registered/unregistered) of the Indigenous Systems of Medicine and Homoeopathy, and (ii) the unregistered practitioners of the modern system. 15.1 Without entering upon any debate on the relative merits of the various systems of medicine it must need be emphasised that in any exercise in medical manpower planning it would appear unavoidable to take into account all those who are actually rendering medical and health care services to the peopled Also, in terms of planning of services for future and computing manpower requirements a definite view would require to be evolved regarding the nature and extent of burden to be borne by the various systems of medicine. Also, as regards requirements of technicians, para-medical personnel etc. it would be necessary to assess their need alongside the exercises to project the demand for doctors and specialists. Such a conjoint view is necessary to ensure that manpower planning adequately takes into view the Health Team approach. It is, therefore, imperative that Government should arrive at a clear view in regard to these issues. 16. The efforts made by the IRMS may be seen in their report at Appendix IX, specially the Tables 1—12. On the basis of given assumptions, projections have been made in regard to future increases (until 000 A.D.) in the existing stocks of doctors deists. Nurses and pharmacists further, on the basis of assumed ratios regarding the targetted scale / coverage of health services in the period uptill 2000 A.D. projections have been made regarding the requirements of the aforesaid categories of personnel, adjusting for given attrition rates. Finally, relating the projected requirements to the corresponding stocks, a picture of the likely surplus /deficit of manpower has

also been arrived at, category-wise for given points of time. As stated in Appendix IX, Ihe projections are based on secondary data for want of the essential statistics. 16.1 It does not appear necessary to make any critical comments on the projections contained in Tables 4 (A & B), 5—12, of the IRMS Report (Appendix IX). While, obviously, a meaningful effort at medical manpower planning can be undertaken only after resolving the issues referred to in paras 7, 8, 9 and 12 it would be worthwhile for the various Central Councils and Specialists Associations to examine the implications of the IRMS projections, specially to arrive at a view regarding the assumptions involved therein. The Ministry of Health and family Welfare may also like to consider early further action in the matter, in consultation with the I.C.M.R. and the Planning Commission. 17. In view of the discussions in the paras foregoing it would be appreciated that the Sub-Com-mittee is not in a position to make any concrete recommendations regarding the changes required to be brought about in the existing scale of production of personnel of various categories, to meet the manpower requirements in the future. 17.1 Grateful thanks of the Sub-Committee are due to Shri M.C. Verma, Joint Adviser, Man-power Unit, Planning Commission and to Dr. Usha K. Luthra, Senior Deputy Director General, Indian Council of Medical Research, for their help and assistance. The statistical projections would not have been possible but for the prompt help and assistance of the Institute of Research in Medical Statistics. Our thanks to Dr. A. D. Taskar, Director, Institute of Research in Medical Statistics, Dr. N. N. Singh, Senior Research Officer and Miss Shibani Bhattacharjee.