INTRODUCTION

India was elected as the chairperson of the G-20 group from 1 December 2022 for a 1 year period. In a summit in the third quarter of 2023, the United Nations General Assembly, after a mid-term meeting of its members, released the declaration of sustainable developmental goals (SDG). These declarations were meant to shape the world we want for our future generations by 2030.1 The goals have been summarized below:

No poverty

Zero hunger

Good health and well-being

Quality education

Gender equality

Clean water and sanitation

Affordable clean energy

Decent work and economic growth

Industry, innovation and infrastructure

Reduced inequalities

Sustainable cities and communities

Responsible consumption and production

Climate action

Safety of life below water

Safety of life on land

Peace, justice and strong institutions

Partnership for achieving these goals

Of these, goals 3, 4 and 9 are pertinent and related to the healthcare profession; goal 3 since the profession has direct responsibility for ensuring the quality of healthcare professionals to serve the community and influence adequacy of numbers, although that may be a primary responsibility of the government and the regulatory agencies; goal 4 to ensure that quality service reaches the community by training healthcare professionals of sufficient competency to fulfil their work-related requirements and goal 9 to focus on healthcare innovations which not only would ensure outreach of good service, but also go towards providing affordable care at the door steps of the community. This paper will focus on the responsibilities of educators of health professions in promoting each of these sustainable goals.

Indices of good healthcare

The mandates for good healthcare are well known.2 They have been published by the Agency for Healthcare and Quality and are listed verbatim below.2

Safe: Avoiding harm to patients from the care that is intended to help them

Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively)

Patient-centred: Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions

Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care

Efficient: Avoiding waste, including waste of equipment, supplies, ideas and energy

Equitable: Providing care that does not vary in quality due to personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.

The above are from the perspectives of the providers of healthcare. They can be rephrased from the point of view of the patient and the community as the 5 ‘A’s of patient centred healthcare:

Available (at the door step or in proximity to place of residence)

Accessible (if at some distance from the user community)

Affordable (either by provision of a workable universal healthcare scheme or by integration of different healthcare systems)

Acceptable (as regards quality of care and competency of care providers); and

Awareness (by word of mouth and by user and usage feedback).

The current situation in India from the point of view of education of competent physicians and availability of adequate numbers of healthcare providers is discussed below.

Role 1 of health professions’ academia (HPA): Ensure adequacy of numbers of healthcare providers.

The WHO global standard for doctor patient ratio is 1:1000.3 As per official figures of Government of India published by Pal and Kumar,4 these have been achieved in 2018. The figures of doctors available in India are:4

Allopathic: 13 lakhs or 1.3 million (Functional 80%: 10.5 lakhs [1.05 million])

Ayush: 5.7 lakhs (0.57 million)

Total functional physicians: 16.2 lakhs (1.62 million)

Doctor–patient ratio in India: 1:834 (as against required 1:1000 of WHO)

Doctor–patient ratio (only allopathic): 1:1400

It is clear that if we take only practitioners of modern medicine, we are still to reach the optimal numbers. However, if we take all practitioners of medicine, we have crossed the goal. If this fact is acceptable, the government should focus on improving healthcare services instead of increasing seats for medicine in allopathy as is being done constantly over the past few years since we need, not more doctors but, better distribution of the healthcare workforce. Doctor–patient ratio alone, however, does not indicate uniform distribution. Adequacy of training in existing medical institutions will be discussed later.

The availability of nurses is even more disturbing. India has currently 0.53 hospital beds/1000 population as per figures released in 2017.5 If one goes by these figures, we require approximately 22 lakh (2.2 million) nurses for a population of 140 crores (1.4 billion) given that the requirement of nurses is 1:4 for patients in general medicine and surgery departments, 1:3 for intermediate units and 1:2 for patients in intensive care units ICUs). We are reported to have 35 lakh (3.5 million) nurses registered in India.5 Hence, it looks as if we have exceeded demand. However, as per WHO standards, we need 2.3 beds/1000 population and not 0.53 that we have. By these standards, we need more than one crore (1 billion) nurses whereas we have only 35 lakhs (3.5 million).

Much of the work for providing first contact care at the doorstep and also in hospitals abroad is performed by allied healthcare workers. We have, in India, only 13 lakh (1.3 million) allied healthcare workers which is drastically short of the requirements.5

The role of HPA is to impress, as a group, on regulatory agencies, decision makers and the Government of India, the importance of these figures and try to change the focus from creating more doctors, who are undertrained due to paucity of teachers and clinical material, to creating more of the healthcare force that we actually require, namely, nurses and allied healthcare professionals. These seats also cater to the poorer in the community whereas the seats available for doctors, being exceedingly high priced, are available only for the rich. The priority must be to train allied healthcare workers in various fields to take medical care really to the doors of the community. This is mandatory to contribute to SDG 3 and 4 goals of the declaration. In most developed countries, a lot of initial contact work and primary care is provided by allied healthcare workers such as physician’s assistants.

Role 2 of HPA: Ensure quality of education of health professionals

The entire effort in India in the past few years has been to increase the number of medical colleges and the number of medical seats available for admission. The current number of medical colleges stands at over 700 and the admissions have doubled from a previous figure of about 70 000 per year. Competency-based medical education has also been introduced from 2019 which is more teacher intensive and small group oriented.6 Nearly 3000 competencies were prescribed, as required to be achieved by the MBBS graduate, in the curriculum released by the regulatory agency in 2019. In addition, acquisition of 125 skills in various subjects had to be pre-certified before the summative examination. This is perhaps the largest number of competencies for an outgoing medical graduate anywhere in the world. Since there has been no simultaneous measure to increase teacher availability, the teacher student ratio has been affected adversely impacting the quality of education.

Besides, lowering eligibility of admission through the National Eligibility and Entrance Test (NEET) process over the years has led to decrease in the quality of the incoming students. Most students chose government medical colleges (which are far fewer in number) due to the lower fees. A report in the Times of India dated 7.2.2024 stated that the median NEET rank of students admitted to government colleges in Delhi was 4597 while in private medical colleges in the city of Puducherry was 596 000.7 This factor, in addition to shortage of faculty and sparsity of clinical teaching material, made the jobs of teachers more difficult. Non-availability of clinical material for teaching has resulted in more emphasis on use of simulators and standardised patients for training. The shortage of teachers has particularly been felt in the departments of pre-clinical and para-clinical disciplines since postgraduate seats in these departments have remained unfilled or incompletely filled for several years due to unpopularity amongst students as a goal for their future career. The National Medical Commission (NMC) has also declared that teachers with non-medical postgraduate degrees in basic sciences would no longer be eligible to be appointed as medical college teachers. These were, till now, taking most of the teaching load due to shortage of medically qualified faculty. One must admit that a welcome addition to the NMC undergraduate curriculum is the Attitude, Ethics and Communication (AETCOM) module with five major competencies and 35 sub-competencies which are a continuous vertical thread in the curriculum and focus on soft skills.8

Competency-based education also requires change of teaching/learning methods from emphasis on large group teaching to small group teaching, for which facilities such as adequate number of classrooms (considering that batches may be as many as 250 strong), sufficient number of teachers to engage the small groups and adequacy of simulation material becomes even more important. The evaluation system should also shift from periodic internal assessment to continuous learning place-based assessment (LPBA) using methods such as objective structured clinical examination (OSCE)/objective structured practical examination (OSPE), mini-clinical evaluation exercise (CEX) and other assessment methods previously used only for postgraduates irregularly. The erstwhile workplace-based assessment (WBA) methods have to modified and applied to undergraduates as LPBA methods. Besides, project-based training and training in research methodology should become compulsory for undergraduates to foster the skill of life-long learning for generating evidence-based medicine which is a prescribed skill as per the AETCOM module.

The third lacuna in the training of medical graduates is the complete absence of inter-disciplinary teaching along with their fellow health-professional learners in nursing, or allied health sciences. Multidisciplinary teamwork is exceedingly important in several areas such as managing accident victims, providing disaster relief, contributing to national programmes, providing health education and community outreach services. There is no provision at present for multidisciplinary training in health professions education. Unless these areas improve, the quality of healthcare will remain unsatisfactory.

The fourth and final lacuna in producing the Indian Medical Graduate (IMG) is the total absence of focus on training of allied health science professionals. The numbers as mentioned earlier are exceedingly unsatisfactory. Allied health science graduates play an important role in providing first contact healthcare in developed countries. For example, a physician’s assistant in the USA is capable and provides services not only in hospitals but also as first contact healthcare provider to the community whose services are available at the doorstep. They are able to manage wounds and provide dressings, administer injections, take history and do a physical examination and record their findings, provide follow-up and advise how to follow drug-related instructions, send, receive and interpret laboratory investigations and provide first aid and transport to accident victims.

The role of the HPA in this aspect (Role 2) cannot be overemphasized. They should be the ambassadors of change for lobbying for these modifications in the teaching/learning system, promote the training of allied health science professionals and focus on developing the IMG with all the prescribed attributes. This measure will again ensure contribution to SDG goals 3 and 4. Without pressure from the profession, it is unlikely that the regulatory agency on its own, or the government, would bring about the required massive changes in the teaching/learning system. Without these follow-up actions, there is no question of attaining good health and wellness. HPA should also emphasize in the curriculum, the well-known benefits of prescribing generic drugs so that the community would accept the initiative of the government in ensuring generic drugs of good quality at a considerably less price than patent drugs.

Role 3 of the HPA: promoting wellness.

Aaron Antonovsky has described health and illness as being a continuum with wellness at one end and illness at the other and propounded the theory of Salutogenesis or focus on wellness as opposed to pathogenesis or focus on illness after his research on survivors of the concentration camps during Nazi Germany. He found after interviewing several survivors of the concentration camps that those who survived the holocaust were those who focused on Salutogenesis as opposed to the others who did not survive and who were fixed on a bad outcome. As a consequence of this theory, he proposed a Coherence theory which mentions that those who survived had the following attributes namely, comprehensibility or understanding of what is happening to them, meaningfulness or understanding why it was happening to them and manageability or confidence in their ability to overcome the adversity.9

Based on this, modern medicine should focus not only on healing or palliation but also promoting wellness. It is well established that complementary medicines such as yoga and music are great promoters of relaxation, well-being and relief from anxiety and stress. Our institute has generated evidence of the benefits of complementary medicine to promote wellness in addition to complementing the effect of Allopathy.10 Around India and the world, complementary medicine practices are gaining greater acceptance.

The role of HPA is to recognize the role of complementary medicine as an adjunct in managing illness which hitherto was treated only by modern medicine. Such measures can effectively relieve anxiety, alleviate pain, promote relief from stress and generate a feeling of wellness. This initiative will facilitate SDG goal 3. Till now, modern medicine and complementary medicine have been antagonistic. This attitude has to change for holistic healing.

Role 4 of HPA: Promoting innovations in healthcare

The role of innovations in medicine, and developments of patents and copyrights, has traditionally not been emphasized during undergraduate or postgraduate education. Simple innovations can go a long way in taking healthcare to the masses. It is necessary to include in the curriculum, time for training on healthcare related innovations and the role of developing intellectual properties both in patient care and in one’s own career. In our university, training in intellectual property rights is embedded in the curriculum and this policy, over the years, has resulted in several innovations that have hugely contributed to healthcare. Some of the examples are given below (Fig. 1).

Fig 1. Showing influence of innovations on healthcare. (a) Rapid response disaster relief camp kit (RR drum kit), Indian Granted Patent No: 386826. (b) Universal back resting device, Indian Granted Patent No: 336726. (c) Foldable community patient couch, Indian Patent Application No: 202341055545, (d) Two-wheeler health nursing

Export to PPT

Modification of a simple plastic chair by incorporating a back rest with an extension device and a provision of folding backwards by including a hinge and a stopper. With this device which is transportable, healthcare is provided to patients at their doorstep by the department of Public Health Dentistry. It was developed by a faculty member of the department and patented.

A foldable cot which has been invented and patented by a group of undergraduate students of physiotherapy and which is used for taking physiotherapy to the community.

A disaster management box whose handle can be extended outwards to serve as a drip stand. The inside of the box has several compartments which can be used for storing bandages, drugs, syringes, drip bottles, etc. This has been invented by the department of nursing and is used to provide emergency care at the site of accidents. Once again, this has been patented.

The nursing department has devised a two-wheeler ambulance concept which is equipped with drugs and other equipment for service to the community at their doorstep.

Another useful innovation, recently publicised by Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry, was the use of drones to successfully deliver emergency and other drugs to the community at their doorstep.

There are innumerable such possibilities which never see the light of day due to lack of awareness and emphasis by HPA and consequent lack of training of students to indulge in such creative activities. HPA must ensure embedding the principle of outreach and taking healthcare to the community and the role of innovations to make this feasible to enable a larger contribution to outreach efforts. These are related to SDG goal 9.

Focused attention to these issues by all members of those entrusted with teaching and training of healthcare professionals would go a long way in promoting the SDG goals to which Government of India is committed, and taking them to peripheral areas so that the goal of good healthcare to the community and ensuring quality service to the masses is attained. Even if these measures are started immediately by policy changes, we may not be able to achieve the target by the specified year of 2030. However, it would certainly be possible by 2047 marking 100 years of our independence. All that is required is awareness of our roles as HPA, required regulatory and government support, motivation and good will. All the five ‘A’s of patient-centred healthcare would have been achieved.

The future lies in HPA playing an important role in and outside the classroom which hitherto they have not played. It is necessary as part of their traditional job to influence classroom activities so that a competent graduate candidate can be created, the IMG, by adopting suitable methods of teaching/learning and evaluation aligned with the CBME, motivate the IMG to be lifelong learners and motivate them on the need and the process of fostering and contributing to innovations to take their profession to the door steps of the community. Outside the classroom, the movement created by the HPA should influence policies of the regulatory agencies and the Government of India towards this direction so that India as a nation and HPA as a community can contribute towards the SDG of taking healthcare developments to the community.

The task of emphasizing the teaching community’s responsibility outside the classroom in addition to inside the classroom will enable attainment of the goal of providing for the 5 ‘A’s to the community at their doorsteps with the G-20 declaration fortuitously accelerating this process by 2047, the 100th year of India’s independence.

THE ROAD AHEAD

Having seen the possibilities for sustained participation of the HPA in achieving the SDG goals, one needs to prioritize these activities as regards those that are achievable immediately, those that will fetch results in the intermediate term of 3–5 years, and those which require change in mindset and attitudes, require policy changes and may take longer to come into practice but nevertheless require initiation of action which will bring to fruition the intended outcome in the future. All HPA must first realize their role in these responsibilities as part of their professional duties having been entrusted with the task of providing healthcare to the community and realize the justice of the SDG goals in ensuring the same.

Low hanging fruits

The requirements under role 2 of ensuring quality of the outgoing graduate can be achieved almost immediately by lobbying with the regulatory system to allow for continuous formative assessment which has weightage of at least 50% in the summative examination using LPBA methods as appropriate to the competency being certified. The regulatory agency needs to approve the same and also mandate the FDP required for this purpose. This will ensure competency of the outgoing graduate to provide quality healthcare. The curriculum has also to be revised accordingly keeping the outcomes required in mind, introduce inter-disciplinary teaching and remove redundancies. A modular teaching approach will facilitate the process.

The role of promoting Salutogenesis can also be achieved almost immediately by starting of centres of Salutogenesis in HPE or in the interim have memorandums with such centres to facilitate the process. This effort will be greatly aided by the Government of India’s mindset to promote complementary medicine activities. Research must be planned and executed jointly to generate evidence in favour of the role of complementary medicine in promoting Salutogenesis as adjuncts to modern medicine. This would add Indian data to that already available.

Active exposure of all students to the concept of intellectual property right activities and the importance of fresh ideas and patents in promoting taking of healthcare to the masses should be made mandatory in all medical colleges and should be embedded in the curricula of all HPE programmes. The effect of such an approach in our institute and the products of that training have already been mentioned under role 4. This will fructify in the intermediate term and will contribute to taking healthcare to the door steps.

A long-term united approach is required to influence government policy to shift from focusing on starting more medical colleges to starting more colleges for nurses and allied healthcare workers and physicians’ assistants, who are the actual emissaries of medicine in taking healthcare to the community and ensuring quality, access and comfort. Starting more medical colleges with sub-optimal faculty, inadequate clinical load and poor facilities will only create under-trained physicians who, anyway, would rather prepare for the postgraduate entrance examinations than go and serve the community.