Monday, September 09, 2019
Empowering primary care practitioners
It is important to reclaim health care from ivory tower structures called ‘hospitals’ and incentivise general practitioners
What is special about Japan in the context of health-care services is that it managed to contain the clout of specialists in its health-care system and accorded a prominent voice to its primary care practitioners (PCP) in its decision-making processes.
Hospitals, for the early part of Japan’s history with modern medicine, catered only to an affluent few. The government limited the funding of hospitals, restricting them to functions like training of medical students and isolation of infectious cases. Reciprocal connections between doctors in private clinics and hospitals were forbidden, thwarting the possibility of the two groups creating a strong nexus; on the other hand, a sturdy lobby of clinic-based PCPs evolved to tip the balance in favour of primary health care. The Japanese Social Health Insurance was implemented in 1927, and the Japanese Medical Association (JMA), then dominated by PCPs, was the main player in negotiating the fee schedule.
In India, on the contrary, a hospital-oriented, technocentric model of health care took early roots. Building urban hospitals through public investment enjoyed primacy over strengthening community-based, primary health care. Alongside this, a private sector with rampant, unregulated dual-practice system (doctors practising in both public and private sectors simultaneously) flourished. This allowed doctors to constitute a powerful group held together by coherent interests. This influential doctors’ community, which saw a lucrative future in super-specialty medicine, buttressed the technocentric approach, which also happened to concur with the tastes of the affluent and the middle class. This trajectory of events has had an enormous impact on the present-day Indian health care.
Focus on hospitalisation
While the well-to-do section has always rooted for ‘high-tech’ medical care, this preference has now trickled down to even the subaltern section, which lacks the wherewithal to pay for such interventions. Colossal health insurance schemes like Ayushman Bharat that harp on providing insurance to the poor largely for private hospitalisation — when the most impoverishing expenses are incurred on basic medical care — are at least partly influenced by the passionate popular demand for the so-called high-quality medical care and bespeak the deformity in the health-care system today.
The way this has affected medical manpower and its dynamics also warrants attention. It took 37 years after the landmark Bhore Committee report (1946), which highlighted the need for a ‘social physician’ as a key player in India’s health system, to finally recognise family medicine as a separate speciality — and another decade and a half to actuate a postgraduate residency in family medicine.
The highest professional body representing doctors in this country, the Medical Council of India (MCI), itself came to be dominated by specialists with no representation from primary care. There is a proposal to replace the MCI with a National Medical Commission (NMC) but the situation is unlikely to be much different with the new organisation.
The current opposition to training mid-level providers under the NMC Act 2019 is another example of how the present power structure is inimical to primary health care. Despite the presence of evidence proving that practitioners of modern medicine (say medical assistants) trained through short-term courses, like those of a 2-3 year duration, can greatly help in providing primary health care to the rural population, any such proposal in India gets robustly opposed by the orthodox allopathic community. Proposals to train practitioners of indigenous systems of medicine, like Ayurveda, in modern medicine are also met with similar opposition.
Such medical assistants, and non-allopathic practitioners, have time and again been written-off as ‘half-baked quacks’ who would only endanger the health of the rural masses. Such criticism ignores the fact that nations like the U.K. and the U.S. are consistently training paramedics and nurses to become physician assistants or associates through two-year courses in modern medicine.
Examples of U.K., Japan
Many countries, including the U.K. and Japan, have found a way around this by generously incentivising general practitioners (GPs) in both pecuniary and non-pecuniary terms, and scrupulously designing a system that strongly favours primary health care. What this careful nurturing has meant is that while a community of professionals in our part of the world has thwarted positive change, professionals of the same community in these countries have helped defend that very positive change.
Three broad takeaways emerge. One, it is imperative to actively begin reclaiming health from the ivory towers called ‘hospitals’. This could help in gradually changing the expectations of the layman and reversing the aspirations of medical professionals from being unduly oriented towards high-tech, super-specialty care. Given the current trends, however, this looks like a far-fetched possibility.
Two, we need to find a way to adequately empower and ennoble PCPs and give them a prominent voice in our decision-making processes pertaining to health care. This can create a bastion of primary health care professionals who can then fight to keep their enclave unscathed. Three, a gate-keeping system is needed, and no one should be allowed to bypass the primary doctor to directly reach the specialist, unless situations such as emergencies so warrant. It is only because of such a system that general practitioners and primary health care have been able to thrive in U.K.’s health system. In view of the current resurgence of interest in comprehensive primary health care in India, one earnestly hopes that these key lessons will be remembered.
Dr. Soham D. Bhaduri is a Mumbai-based doctor and Editor of the journal ‘The Indian Practitioner’
Incredible Journey
A householder devotee asked Sri Ramakrishna, “How does one make acquaintance with the Lord?” The sage replied, “If you merely sit on the shore of a lake and say there are nice fish in the lake, will you catch any? You will have to go and get the things necessary for fishing — a rod and line, and bait — and throw some lure into the water and wait. Then from the deep water the fish will rise and you will be able to see and catch them. You wish me to show you God while you sit quietly without making the least effort. Make the effort”. In spiritual terms the effort we put into seeking divinity becomes our sadhana, our spiritual discipline. Sadhana is essentially a code of self-imposed discipline and practice that the sadhak (practitioner) willingly undergoes for spiritual uplift. A healthy desire to grow spiritually fuels the sadhak’s journey. The tapas involved purifies and burns the dross. Sadhana raises your consciousness from the physical to the metaphysical, conferring sweetness and grace. A life without spiritual awakening is incomplete, however successful it may be in worldly terms. Sadhana leads one to the nivritti marg, inward path, as distinct from pravitti marg, which leads to the outside, objective world. All scriptures say that right living is built primarily on the pillars of eternal values like sathya, dharma, shanti, prema and ahimsa. These values have to be brought to the fore by sadhana.
Source: Economic Times, 9/09/2019
How college students outsource homework
Websites Now Let People In Developing Nations Bid For And Complete Assignments Of Pupils In US, UK & Oz
Tuition was due. The rent was, too. So Mary Mbugua, a university student in Nyeri, Kenya, went out in search of a job. At first, she tried selling insurance policies, but that only paid on commission and she never sold one. Then she sat behind the reception desk at a hotel, but it ran into financial trouble. Finally, a friend offered to help her break into “academic writing,” a lucrative industry in Kenya that involves doing school assignments online for college students in the US, Britain and Australia. Mbugua felt conflicted. “This is cheating,” she said. “But we have to make money to make a living.” Cheating in college is nothing new, but the internet now makes it possible on a global, industrial scale. Sleek websites have sprung up that allow people in developing countries to bid on and complete American homework assignments. The essay-for-hire industry has expanded significantly in developing countries with many English speakers, fast internet connections and more college graduates than jobs, especially Kenya, India and Ukraine. A Facebook group for academic writers in Kenya has over 50,000 members. It is not clear how widely sites for paid-to-order essays, known as “contract cheating” in higher education circles, are used. A 2005 study of students in North America found that 7% of undergraduates admitted to turning in papers written by someone else, while 3% admitted to obtaining essays from essay mills. Cath Ellis, a leading researcher on the topic, said millions of essays are ordered online every year worldwide. “It’s a huge problem,” said Tricia Bertram Gallant, director of the academic integrity office at the University of California, San Diego. “If we don’t do anything about it, we will turn every accredited university into a diploma mill.” In an email, EssayShark’s public relations department said the company did not consider its services to be cheating, and that it warned students the essays are for “research and reference purposes only” and are not to be passed off as a student’s own work. Contract cheating is illegal in 17 states, but punishment tends to be light and enforcement rare. Experts said that no federal law in the US, or in Kenya, forbids the purchase or sale of academic papers. Contract cheating is harder to detect than plagiarism because ghostwritten essays will not be flagged when compared with a database of previously submitted essays; they are generally original works — simply written by the wrong person. In Kenya, a country with a per capita annual income of about $1,700, successful writers can earn as much as $2,000 a month, according to Roynorris Ndiritu, who said he has thrived while writing academic essays for others. As for Mbugua, she said she never felt right about the writing she did in the names of American students and others. But adds: “People say the education system in the US, UK is on a top notch. I wouldn’t say those students are better than us. We have studied. We have done the assignments.” NYT
Source: Times of India, 9/09/2019
Friday, September 06, 2019
Teaching in the time of consumerism
Changes in social ethos and state policy have pushed the once-venerated Indian teacher to the margins of public life
Like many other topics, teaching and those who earn a living by teaching are subjects of a highly polarised debate in our country. Public perception of schoolteachers is quite negative in many parts of the country. If you ask a young urban audience: ‘Who wants to be a schoolteacher?,’ the answer will come with so much hesitation that you will be right to summarise it as: ‘No one, really.’ You can verify this by asking freshly enrolled students at a teacher-training course: ‘Was teaching your first preference?’ Very few will say, ‘yes.’ Among young men, there will probably be no one answering in the affirmative.
This low popularity of school teaching can be linked to several changes that social ethos and state policy have gone through over the last three decades or so. In a consumption-oriented environment, the kind of idealism school teaching requires is not easy for a young person to cultivate and sustain. The working conditions and ethos at their respective schools erode the stamina of the few who start with a sense of dedication.
I hardly need to add that this macro picture conceals the tales of several thousand teachers who battle on and remain committed to their duty against all odds. Some of them do get appreciation from parents of the students, but more often than not, parents remain dissatisfied. Many parents now treat their progeny’s school life as an ‘investment’ for which they demand the best ‘value’, often by relentlessly criticising the teacher and the principal. They don’t know the burden teachers carry on their fragile, ill-equipped professional shoulders. This burden includes the weight of family and community life, and the pressure coming from officialdom.
On their part, children bring to schools the psychological bruises incurred at home where the adults are too preoccupied with their own lives. Further, as recent surveys in both urban and rural habitations show, technology is a dominant player in child upbringing. A schoolteacher must cope with the impact that these drastic changes have made on the inner world of children.
Weak professional training
Speaking of training, the vast majority of teachers being hired today have had their professional training in poorly equipped institutions. Weak professional preparation is not a recent woe, but it has certainly worsened under the ‘licensing raj’ of the National Council of Teacher Education (NCTE). There was a time when teacher training had no licensing authority. The NCTE was an advisory body then, with no statutory powers. It acquired legal teeth as a result of the NCTE Act, 1993. The new, empowered NCTE came into being two years later.
The mid-1990s marked a period of tumultuous change in the landscape of public education. The impact of market-friendly policies was spreading across the system, but it was the most palpable in professional education. Private enterprise in medical, engineering and management education had already set in. Compared to these areas, teacher training was both cheap and highly profitable.
Demand for qualified teachers rode the wave of rapid growth in primary education. In response to this demand, teacher-education institutes and correspondence courses mushroomed. The NCTE had a difficult mandate to fulfil and had to maintain standards by regulating a bullish market of enrolment providers. Initially, it seemed as if the NCTE’s regulatory role would succeed in imposing quality norms. However, before long, the body’s failure to control the flood of commercial private interests started looking inevitable.
Teacher training was, of course, not the only area of professional education to be corrupted by the new licensing regime. The system of education was in general battling hard to find ways to regulate the swelling, strong current of privatisation.
The teacher-training sector became so afflicted by fraudulent institutions and practices that internal mechanisms of correction proved inadequate. Hundreds of cases against bogus institutions reached the Supreme Court, which appointed a commission chaired by late Justice J.S. Verma. For a few years after 2012, when its report was published, an attempt was made to implement its recommendations, but the momentum slowed down before long. Several recommendations required substantial state funding, but the NCTE had already taken the self-financing route. Its institutional capacity to provide academic leadership to teacher training was already limited. Its further decline coincided with the rise of technological gimmickry. However, it would be wrong to hold the NCTE alone responsible. The wider problems of higher education have also made their contribution to the decline of teacher training. This is not hard to explain. Graduates whose college education is of poor quality cannot be expected to overcome their learning backlog at a training institute. Faculty shortage exacerbates this deprivation.
The government recently came up with a policy decision favouring four-year courses that integrate undergraduate learning with pedagogic training. This model is not new, and its success depends on investment in institutional infrastructure. But with commercialisation fully entrenched in teacher education, one cannot expect generous spending on faculty and infrastructure.
Impact on school education
Problems of teacher training have had a pervasive impact on school education as a whole. Governments have been aware of this, both at the Centre and in the States. One of the steps they have taken to fill the quality gap is to introduce a teacher-eligibility test. This has only made a marginal difference, as the proportion of trained teachers who get through the test is low, creating a vast backlog in recruitment. On the other hand, para-professionals have been growing in number and influence. They are known by various names in different States, but they also exist in vast numbers outside the system — as providers of home tuition and coaching. This underbelly of the education system suffers no interference from state norms. In the world of coaching, we see the utopia of free enterprise and the demise of teaching as noble work.
It is hard to date the beginning of the current, ongoing decline in the status of teachers. A conversation with a senior official in Madhya Pradesh comes to mind. During a visit to Bhopal more than two decades ago, I asked him if it was correct to say that school teaching was no longer considered a career in M.P. He readily agreed. We discussed the new realities that had emerged. We agreed that a major shift in culture, pushed by economic changes, had occurred, and it had marginalised the teacher.
The Indian teacher, once a foot soldier in the freedom struggle and a contributor to nation building in the early years after Independence, now stands relegated to the margins of public life. This marginalisation is reflective of the social change that has taken place in the country and flags the diminishing importance of intellect. This is also evident from the news about our greatest historian being insulted by her university. Our collective vulnerability to the power of propaganda and rumour is not new; disrespect for the teacher’s dedication to a life of intellect is.
Nonetheless, no matter what the subject and howsoever limited his or her own knowledge, every teacher tries to nudge his students towards reality and truth. Children want their teacher to verify and appreciate their efforts. Having faith in his/her teacher is a part of being a child, a blow to which will disturb the foundations of social living.
Krishna Kumar is a former director of the National Council of Educational Research and Training (NCERT)
Source: The Hindu, 6/09/2019
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