Article

Comparative study of community medicine practice in MBBS curriculum of health institutions of Nepal

Department of Community Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.
Kathmandu University Medical Journal 01/2010; 7(28):461-9. DOI: 10.3126/kumj.v7i4.2775
Source: PubMed
ABSTRACT
A revolution in health care is occurring as a result of changes in the practice of medicine and in society. Medical education, if it is to keep up with the times, needs to adapt to society's changing attitudes. Presently medical education has been criticised for its orientation and insensitivity to people's need. The MBBS curriculum of medical institutions of Nepal has been focusing on community-based approaches and is still guided by the same notion. The question put forward is whether it has been appropriate to nurture the present health needs and aspiration of people.
The objective of the present study is to review the existing community based medical education in health institutions of Nepal to strengthen the components of community care.
Qualitative study was done by reviewing the curricula and existing community medicine courses/activities in MBBS curriculum of Institute of Medicine (IoM)/Tribhuvan University, BP Koirala Institute of Health Sciences (BPKHIS) and Kathmandu University School of Medical Sciences (KUSMS).
The curriculum of all the health institutions have addressed significantly on community medicine practice. As per Institute of Medicine, the community medicine practice is achieved through community based learning experiences like community diagnosis, concurrent field with families of sick members and district health system management practice. In BP Koirala Institute of Health Sciences, community medicine practice is undertaken through exposure to community diagnosis program, health care delivery system, family health exercise, applied epidemiology and educational research methodology, management skills for health services and Community Oriented Compulsory Residential Rotatory Internship Program (COCRRIP). In KUSMS, community medicine module is carried out as- community diagnosis program, community health intervention project, school health project, occupational health project, health delivery system functioning, family health care activities and Compulsory Residential Rotatory Internship Program in outreach clinics. In the practice the practical aspects are largely unstructured that waste too much time in non-educational activities and rely on learning and doing. Meanwhile, expectation of the community is increasing and the challenge of nurturing their demands has come in forefront. Community has perceived that the medical schools are concentrating on fulfilling the demand of their curriculum rather directing on their health care need.
Health institutions need to be accountable to take the responsibility of strengthening the health status of the community of their catchments areas. The practice of community medicine need to be done in an innovative way and these schools should execute continual intervention activities and complement other institutions working in their areas.

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Kathmandu University Medical Journal (2009), Vol. 7, No. 4, Issue 28, 461-469
Medical Education
Comparative study of community medicine practice in MBBS
curriculum of health institutions of Nepal
Marahatta SB
1
, Sinha NP
2
, Dixit H
3
, Shrestha IB
4
,
Pokharel PK
5
1
Assistant Professor, Department of Community Medicine,
2
Professor, Department of Community Medicine, Kathmandu
University School of Medical Sciences, Dhulikhel, Nepal,
3
Professor, Department of Paediatrics, Kathmandu Medical
College, Kathmandu Nepal,
4
Professor, Community Medicine and Family Health, Institute of Medicine Tribhuvan
University, Kathmandu, Nepal,
5
Professor, Department of Community Medicine BPKIHS, Dharan Nepal Kathmandu Nepal
Abstract
Background: A revolution in health care is occurring as a result of changes in the practice of medicine and in society.
Medical education, if it is to keep up with the times, needs to adapt to society's changing attitudes. Presently medical
education has been criticised for its orientation and insensitivity to people’s need. The MBBS curriculum of medical
institutions of Nepal has been focusing on community-based approaches and is still guided by the same notion. The
question put forward is whether it has been appropriate to nurture the present health needs and aspiration of people.
Objective: The objective of the present study is to review the existing community based medical education in health
institutions of Nepal to strengthen the components of community care.
Materials and methods: Qualitative study was done by reviewing the curricula and existing community medicine
courses/activities in MBBS curriculum of Institute of Medicine (IoM)/Tribhuvan University, BP Koirala Institute of
Health Sciences (BPKHIS) and Kathmandu University School of Medical Sciences (KUSMS).
Findings and Discussion: The curriculum of all the health institutions have addressed signi cantly on community
medicine practice. As per Institute of Medicine, the community medicine practice is achieved through community
based learning experiences like community diagnosis, concurrent eld with families of sick members and district health
system management practice. In BP Koirala Institute of Health Sciences, community medicine practice is undertaken
through exposure to community diagnosis program, health care delivery system, family health exercise, applied
epidemiology and educational research methodology, management skills for health services and Community Oriented
Compulsory Residential Rotatory Internship Program (COCRRIP). In KUSMS, community medicine module is carried
out as- community diagnosis program, community health intervention project, school health project, occupational health
project, health delivery system functioning, family health care activities and Compulsory Residential Rotatory Internship
Program in outreach clinics. In the practice the practical aspects are largely unstructured that waste too much time in
non-educational activities and rely on learning and doing. Meanwhile, expectation of the community is increasing and
the challenge of nurturing their demands has come in forefront. Community has perceived that the medical schools are
concentrating on ful lling the demand of their curriculum rather directing on their health care need.
Conclusion: Health institutions need to be accountable to take the responsibility of strengthening the health status of the
community of their catchments areas. The practice of community medicine need to be done in an innovative way and
these schools should execute continual intervention activities and complement other institutions working in their areas.
Key words: Community medicine, curriculum, eld practice
B
iomedical sciences and clinical medicine have
achieved phenomenal advancement and successes
during the past 50-60 years. The new and ever improving
diagnostic, pharmacological and instrumental
armamentaria have made physicians increasingly
effective and powerful in combating diseases
1
. Advances
in medical sciences and technology are but a part of these
events. Since there is an organic relationship between
medicine and human advancement, the evolution of
medical education should be viewed against civilisation
and advancement at that time
2
. There was noticeable
development in medical education as the theory of
disease causation changed from supernatural to germ
causation and from genomics to proteomics. In this
Correspondence
Sujan B. Marahatta
Department of Community Medicine
Kathmandu University School of Medical Sciences
Dhulikhel, Kavre
E-mail: sujanmarahatta@gmail.com
Page 1
462
regard, medical education needs to be directed to aspire
not only the teaching of diagnosis and management, the
mainstay of medical education for the last hundred of
years or more, but optimum health requires more than
this. The role of medical education has been to produce
professionals who can understand and assume their
responsibilities to meet the wider health care need of
their people to remain physically, mentally, socially
and spiritually healthy as envisaged by WHO. Equally
reassuring for the future of medicine is the continued
evolution of medical education itself
3
.
Medical education should evolve based on science
to serve patients. Despite the innovation in medical
arena, the developing countries are lagging behind to
reap the bene ts. The importance of primary health
care components in health care delivery system is
still evident. Therefore, it has become necessary to
incorporate ingredients of primary health care to
reinforce the medical education. With the existing
system, to facilitate the health care delivery approach,
community care needs to be incorporated and practiced.
Obviously, health science students need to be equipped
with the essential knowledge and skills to address
these issues. Community based medical education is
the theme of medical education of Nepal. The current
practices related to the community-centred education
need to be analysed and strengthened to address the
wider need of the community.
The purpose of the present study is to review the
existing Community Based Medical Education in Health
Institutions of Nepal to strengthen the components of
community care.
Materials and methods
As the intent was to elicit and explore issues related
to community based medical education, the authors
selected a qualitative approach to compare the
philosophy and existing community medicine courses
of the MBBS programs of Institute of Medicine /
Tribhuvan University, BP Koirala Institute of Health
Sciences and Kathmandu University School of Medical
Sciences. Basic information on the philosophy and
contents of the community medicine was obtained from
the MBBS curriculum of the respective institutions and
the departments of the community medicine and from
published documents.
Findings
A. Philosophy and Concept of Community
Based Medical Education in IOM/ Tribhuvan
University
The Institute of Medicine (IOM) was established in
1972 under Tribhuvan University and had the mandate
and the responsibility of training all the categories of
health manpower needed in the country.
In the beginning the stress was on training of middle
level health workers. The programmes run for this
purpose were ANM, CMA, and Pro ciency Certi cate
Course in General Medicine, Pharmacy, Radiology,
Physiotherapy, Nursing, Health Laboratory and
Traditional Medicine.
With the passage of time, institutional goals of IOM
have kept on changing. With the demand of time,
institutional goals to IOM have been entrusted with a
new responsibility of training the human resources for
health of tertiary level health professionals. By 1977
it had at graduate level, a 2-year Bachelor of Nursing
Programme in Community Nursing, Paediatric Nursing
and Adult Nursing.
In 1978, a community-oriented integrated MBBS
programmes was started with intake of 22 students.
Later on it was made 30 and it was subsequently
increased to 40. The current intake of MBBS students is
61 as per the annual report of 2009.
A three hundred-bedded TU Teaching Hospital was
completed in 1984 with support from JICA and another
100 beds were added in 1993. Tribhuvan University
Teaching Hospital is now an almost 800 bedded
hospital. This hospital is being used for the teaching/
learning activities of different programmes run by IOM;
it also carries out the research work.
At post-graduate level, a three year Postgraduate
Generalist (Family Physician) Training in 1982 and one-
year Postgraduate Diploma in Anaesthesiology in 1984
were started with the support from the University of
Calgary, Canada. Today the IOM is running 29 different
programmes from pro ciency certi cate level to the
highest postgraduate degree in medicine, public health,
paramedical, nursing and traditional medicine (Ayurved
Science) through 9 campuses scattered all over the
country, Tribhuvan University Teaching Hospital, and
various academic programmes in the near future. It also
has 5 af liated campuses.
The goals of IoM are:
Production of human resources for health services,
education and research
Provide health services through its health
institutions
Conduct research in health sciences
MBBS program at the Institute of Medicine was
conceived and started in response to the national health
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463
needs identi ed through district health surveys in rural
districts (Tanahu, Bara, Nuwakot and Dhankuta) which
were carried out to develop need-based curriculum. The
survey results provided the basic data necessary for
curriculum planning. The job description of medical
of cer was analysed. The curriculum was designed on
the basis of the health needs and perceived relevance
to the community, and the roles to be performed by
the medical graduates to serve the health services
in the districts of Nepal. Despite passage of time
it has remained true to the ideals that motivated its
establishment. In 1978 the program was conceived as
Medical Science Diploma of Doctor of General and
Community Medicine (MSDDGCM)
4
. It was later
however termed a MBBS when the rst batch quali ed
in 1984.
This program is known for its strong community
orientation and stress on integrated learning of basic
science subjects. In addition, the strategies of promoting
problem based self directed learning adopted by this
institute helps our graduates to prove their abilities in
different situation. However over the years there have
been many comments on MBBS program of IOM. At
the time when community based medical education
was introduced in Institute of Medicine, it was viewed
sceptically as producer of third grade graduates and
barefoot doctors. Community based medical education
has been viewed as not being based on science and for
neglecting the importance of premedical courses. The
graduates were blamed for not being competent in
dealing with the patients as they spent most of their time
in the community than in the hospital. Another handicap
was not being recognised in other countries. The
community-oriented physician, trained in a community
oriented medical education system was referred to as a
substandard species.
IoM had to face a lot of opposition to this type of
thinking. With all the above resistance, IoM is the rst
medical institution in Nepal to introduce community
orientation, systems approach, problem-based and
integrated teaching.
Institute of Medicine has a mandate and responsibilities
different from many other medical colleges, it being a
public sector institution created with the government
funds. The features of IoM are as follows: lower
fees, highly competitive entrance examination yet
still the most sought after medical school in Nepal,
experienced and committed faculty members on
permanent employment of the university, extensive
clinical learning resources including in house internet
server and well established library. Besides, Institute of
Medicine functions almost as a health science university
and conducts a large number of certi cate, bachelor and
postgraduate programmes in different discipline. Plans
are underway to start a Public Health School.
Community Medicine Practice Model
Diagnosis of the state of the health of a community is as
important for community medicine as clinical diagnosis
is for the care of an individual patient. There is a need to
ensure continuing surveillance of the population's health
and evaluation of health care programs. To execute
above mentioned task the knowledge of epidemiology,
biostatistics, demography, sociology, environmental
health, occupational health, nutrition, health nancing,
health related behaviour, health promotion and health
administration is indispensable. Having fundamentals
of these will enable them to identify the state of the
health status of the community, the underlying factors
responsible to precipitate the problem and existing
health care system, their functional aspects, constraints
and challenges. This will broaden their horizon and
enable to think in broad spectrum of health.
Community based practices are essential components
with the speci c aim of developing the student’s
competencies in understanding community health
problem and later to enable them to solve these problems
working with the community. All eld activities are
need-responsive, problem solving, and community
oriented, which encourages students to render services
while they learn and develop clinical and public health
management skills.
Important areas of Community Medicine
Community diagnosis
Community health care
Surveillance of health
Evaluation of the programmes
Curriculum Outline and Implementation Modality
First Year Community Medicine and
Integrated Basic Medical
Science
Second Year Integrated Basic Medical
Science
Third Year Applied Epidemiology,
Family Health Exercise,
Forensic Medicine, Clinical
Subjects
Fourth Year Clinical subjects, District
Health Service Management
Four and half Year Clinical Subjects
Final (one year) Rotating Internship
Approaches to community based learning
Taught courses mostly in 1st year with small
components in the 2nd and the 3rd phases
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464
The community orientation is achieved through
community based learning experiences like
community diagnosis, concurrent eld with
families of sick members and district health systems
management eld.
Community eld programmes are the essential
component of IoM with the speci c aim of developing
the student’s competencies in understanding community
problem and solving these by and through working with
the community. All eld activities are need-responsive,
problem solving, and community oriented, which
encourages students to render services while they learn
and develop clinical and public health management
skills.
B. Philosophy and Concept of Community Based
Medical Education BPKIHS Perspectives
B.P Koirala Institute of Health Sciences (BPKIHS)
established in 1993, upgraded to a deemed university
in 1998, is an autonomous Health Sciences University
with a mandate to work towards developing socially
responsible and competent health workforce. Striving
continuously to meet the health needs at the primary, a
secondary and tertiary level is its primary responsibility.
The medical education at BPKIHS started on October 19,
1994 with the intake of the rst batch of MBBS students.
Gradually it started B.Sc. Nursing in 1996, BDS, MD/
MS, M.Sc. and the CN Programme in 1999, OT and
AS in 2000, BMIT in 2001 and B.Sc. MLT in 2005.
At present altogether 908 students are studying various
programmes. The number of students programme wise
is: MD/MS 155, M.Sc. 18, MBBS 264, BDS 160, B.Sc.
Nursing 54, B. Sc. MIT 18, Certi cate Nursing 120, OT
& AS 17, B.Sc MLT 10, MBBS Interns 57 and BDS
Interns 35. The Institute is started the MPH programme
from September 2005. In order to provide students a
community oriented medical education and to create
a socially accountable health work force in the nation,
this Institute has launched the concept of a ‘Teaching
District’. Presently Sunsari, Morang, Dhankuta, Saptari,
Jhapa and Ilam districts are included, but gradually all
the districts of the entire eastern region of Nepal (16
districts) will be included in teaching districts. In terms
of achieving the educational goals of the Institute both
the present curricula and future educational program
are need based, integrated, community oriented and
partially problem solving in the line with innovative
medical education program epitomised in the Edinburgh
Declaration of 1998.
Mission of BPKIHS
To improve the health status of the people of Nepal
and the neighbouring regions by providing holistic
health care through training of compassionate, caring,
communicative and socially accountable health
workforce acting as catalyst of change and through
advancement in research and innovation in service as
well as education to ensure healthy individuals and
families by collaborating with all stakeholders.
Community Medicine Practice Module
Phase I (Multiprofessional exposure to Community
diagnosis programme)
Objectives
To appreciate working atmosphere in team
To bridge the gap between the professionals
To identify the current scenario of different system
and fragmented care to comprehensive need of
people.
Methodology
Village leaders meeting
Social mapping
House-to-house survey
Focus group discussion
Health education
Health exhibition
Health camp
Report presentation
Phase I Second Year (Health Care Delivery System)
Objectives
To familiarise the students about Health Care
Delivery System
To understand the structure and functions of the
different NGOs /INGOs working in Health
Methodology: Six- eld visits
Sub-health Posts with FCHVs
Primary Health Centres
Teaching District Health Units
SOS Bal Gram, Itahari
Purvanchal Anathasram
Elderly Care Home, Mulghat
Phase II (Third year) Family Health Exercise
Objectives
To analyse the social and cultural variables related
to health and disease in the family
To enable the family care in health and diseases
To work with school hygiene and sanitation of the
area
Methodology
Each Student- Family of ve.
Fifteen Visits: Once in 15 days
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Each Visit: 4 Hours, and to present ndings in Log
Book
Phase II (Third year) Applied Epidemiology and
Educational Research Methodology (EPIDMAN)
Objectives
Appreciate the importance of designing a scienti c
study.
List various epidemiological study designs.
Carryout simple epidemiological study
Report preparation and presentation
Integrate learned knowledge & skills by presenting
accurately in presence of adjunct faculties of Health
Professional Education Dept
Methodology
• Students-10 Groups
Each group-Epidemiological Investigation of
National Health Problems
Phase II (Fourth year)
Management skills for health
services (HEALTH MAN)
Objectives
Understand the activities at all levels of health care
system
Appreciate the importance of managerial skills in
health care delivery services
Observe all activities of Zonal Hospital and District
Public Health Of ce
Familiarise with the mechanism of monitoring and
supervision, including health nancing
• Understand the Health Management Information
System (HMIS)
Methodology
Three Groups – Mechi, Koshi, Sagarmatha Zonal
Hospitals
– District Public Health Of ce
Phase-II (Fifth to ninth semester) Learning in Field
Objective
To work up socio-clinical cases.
To learn about the morbidity and mortality pattern
at the level of primary health centre and district
hospital
Methodology
By visiting to the District Health Of ce, Sunsari,
Sunday, Tuesday and Friday with Faculties
of Medicine, Surgery, Paediatrics, Obs/Gyn,
Orthopaedics, ophthalmology, ENT, Dermatology,
Psychiatry and Community Medicine.
Phase-II (Fifth Year Internship Program)
Community Oriented Compulsory Residential
Rotatory Internship Program (COCRRIP)
Objective
To give Preventive, Promotive and Curative
Services.
To take part in all the activities at Zonal & District
Hospitals
To conduct Health Education Session and School
Health Program.
To learn Managerial Skills.
To carry out a research project.
Methodology
Six month posting at Teaching Hospital (BPKIHS)
Six months at Zonal & District Hospitals
15 days in District Public Health Of ce
15 days in Primary Health Centre
Total Field Posting for MBBS Course
Programs Days
Orientation Courses 5
Multi-Professional Exposure in CDP 15
Health Care Delivery System 6
Family Health Exercise 15
• Learning in Field 84
Applied Epidemiology & ERM 45
Planning for Health Management 15
• Internship
Zonal & District Hospitals 150
District Public Health Of ce 15
– Primary Health Centre 15
Total (days) 365
C. Philosophy and Concept of Community Based
Medical Education in KUSMS
Kathmandu University School of Medical Sciences
(KUSMS) is a not-for-pro t, non governmental medical
college of Kathmandu University (KU). KUSMS was
established in 2001 in joint collaboration with KU and
Dhulikhel Hospital (DH).
Currently KUSMS offers the MBBS Program apart
from other programs in health sciences. The KUSMS
MBBS program is an autonomous program, established
to produce technically competent, socially responsible
and behaviourally compassionate medical graduates.
KUSMS Educational strategy is based on Problem-
Based Learning (PBL) and Community-Based Learning
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(CBL). This is the rst medical college in Nepal
include PBL as an integrated part of the curriculum.
PBL comprises small group tutorial sessions under the
guidance of faculty tutor. Following this, self directed,
independent learning takes place. This is supplemented
by laboratory experiments and lectures on selected
key topics. CBL comprises of Teaching/Learning in
community with regular residential posting as well as
the usual classroom learning.
Community Medicine Practice Module
First Year
Philosophy
To acquaint the students about the phenomenon and
social aspects of health, disease and care
I) Community Diagnosis Program (CDP): 1 Month
II) Observational study
Second Year
Philosophy: To carry out intervention programs to
reduce the health and disease burden in the community
Community Intervention Project focused on:
Awareness on health and diseases
Promotion of maternal and child health
Promotion of hygiene and sanitation/ Environmental
Protection
Uplift health care utilisation behaviour in
community
Third Year
Philosophy: To carry out speci c intervention
programs to reduce the health and disease burden in the
community
Speci c Intervention Project focused on:
School Health
Occupational Health
Study of the health delivery system
Fourth Year
Philosophy
To conduct comprehensive family health intervention
in order to reduce the health and disease burden of
the family
To aware about the national/international health
system and national priority health programs
Comprehensive Family Health Intervention focused
on:
Clinico-social aspects
Internship
Philosophy
To conduct comprehensive health care activities
and to address the health problems at the individual,
family and community level.
Community Medicine Posting
8 weeks in six different outreach centres- Dapcha,
Bhaunipati, Boldhe, Baluwa and Dhading PHCs.
Activities
Patient care
In the patient management at the health centre
working closely with the residential paramedical
staffs and the visiting doctors
Managerial function
In all the activities of the health centre, e.g. record
keeping, dispensing, communication with the
hospital, managing logistics etc.
Health education/promotion activities:
Counselling sessions to the patients in relation to
different diseases.
Special counselling sessions to the patients in
relation to family planning, MCH
Discussion
The philosophy of community oriented medical
education has been to acquaint the students about the
phenomenon of the disease process and underlying
factors and enable them to understand health problems
of the community and acquire clinical/managerial skills
to deal with the public health problems. Looking at the
philosophy and practice of community based medical
education of three institutions of Nepal; it appears
that focus has been given since the beginning of the
year till the end year. As per Institute of Medicine,
the community medicine practice is achieved through
community based learning experiences like community
diagnosis, concurrent eld with families of sick members
and district health system management practice. In
BP Koirala Institute of Health Sciences, community
medicine practice is undertaken through exposure to
community diagnosis program, health care delivery
system, family health exercise, applied epidemiology
and educational research methodology, management
skills for health services and Community Oriented
Compulsory Residential Rotatory Internship Program
(COCRRIP). In KUSMS, community medicine module
is carried out as- community diagnosis program,
community health intervention project, school health
project, occupational health project, health delivery
system functioning, family health care activities and
Compulsory Residential Rotatory Internship Program
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in outreach clinics. In the initial two years, students
are trained to acquire fundamental understanding about
the health and diseases. The community diagnosis
exposure of each institution is focused to enable
the student understand the factors that affect the
health and wellbeing of the individual. It offers them
practical understanding about the factors that trigger
ill health and widen their thinking about the social,
cultural, behavioural, economic and health system. It
enables them to identify the state of the health status
of the community, the underlying factors responsible to
precipitate the problem and existing health care system,
their functional aspects, constraints and challenges. This
will broaden their horizon and enable them to think in
broad spectrum of health.
After community diagnosis, exposure in third year, both
IoM and BPKIHS offer family health exercise to enable
the student to understand the health problems at family
level and offer necessary interventions. However in
KUSMS such exercises are conducted in fourth year.
Prior to sending for family health practicum, the
students gain practical exposures in school health,
occupational health and health delivery system. As per
the orientation of curriculum, BPKIHS has given strong
focus on enabling students to conduct an epidemiological
research to enhance their skills of designing scienti c
study and putting in practice. This seems an innovative
endeavor. The curriculum of all the institutions has
given emphasis in understanding health system of the
country and its framework from grass root level to the
national level. Thus community diagnosis, family health
exercise, study of the health system of the country are
the major areas of the practice in all institutions and in
addition focus in research activities by BPKIHS and
community placements during internships are major
community based activities practiced by BPKIHS and
KUSMS.
Community based practices are essential components
with the speci c aim of developing the student’s
competencies in understanding community health
problem and later to enable them to solve these
problems working with the community. Meanwhile, it
is essential to enable them to be accountable towards
the community and develop as socially accountable
physicians. Looking back to the history of IoM, the
oldest institution in Nepal, has this mission been
achieved? Bearing in mind the fact that as we ourselves
have grown up in community and have our rst hand
experiences there, so is it essential to have community
exposure?
The usual state of affairs is that not more than 10%
of patients visit the hospital and not more than 1%
are admitted. Why do we then continue to limit our
clinical teaching within the walls of the hospital and
claim to be producing competent doctors? For these
doctors to be competent it is vital that they receive a
balanced training in all levels of health care: primary,
secondary and tertiary as well as having familiarity with
the culture, traditions and other psychosocial aspects of
the families and communities within which they are to
practice medicine.
5
Beside all this the practical aspects, being largely
unstructured, waste too much time in non-educational
activities and rely on learning and doing. Meanwhile,
expectation of the community is increasing and the
challenge of nurturing their demands has come in
forefront. Community has perceived that the medical
schools are concentrating on ful lling the demand
of their curriculum rather directing to the health care
needs of the community with which they are involved.
The communities have been used for the sake of
academic pursuit rather than the other way round. Their
awareness about they being used for academic pursuits
has made them reluctant to act as learning tools for
medical students. As a result the communities have
been refractory towards external in uences and have
been reluctant to participate in such works. One of the
reasons is that the urban and suburb communities who
might not be an appropriate target for such purposes
have been used by medical colleges for the sake of
accessibility.
In fact, a large number of the existing community-
oriented medical schools base a large proportion of
their educational activities in the hospital but utilise
ambulatory and out-patient departments as well as
bedside teaching. We are not trying to minimise the role
of bedside teaching, what we are saying is that it should
not be the sole or major mode of clinical teaching, as it
would then be irrelevant
5
.
Medical schools need to continually address on
target areas with continual follow up of the work and
focus on addressing health care needs along with the
academic pursuit. Innovative health interventions
need to be designed and applied as per the reality of
the circumstances. Majority of community-oriented
schools, in addition to trying to make their education
relevant to community health needs, also try their best
to make use of the science of education in their teaching/
learning strategies; this is by no means an easy task, and
a great effort is put into it by both teachers and students.
The aim is to improve and develop medical education.
Therefore, it is illogical to view this in reverse and claim
that it is done for the purpose of producing second- or
third-grade doctors.
5
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468
To strengthen community based medical education
medical institutions need to be accountable and must
design innovative intervention strategy to address the
health problems identi ed in the community
6
. This
endeavour will motivate the community to participate
in such activities. If communities and their active
participation in decision-making and action for health is
the essence of the new public health, then that must be
the starting point for conceptualisation of content and
orientation. People in communities and their resources
and informed choices will be at the core of the health
system, in relation to which all other elements need
to be described and tested for relevance. Enabling
communities to make the best choices for health,
and providing them with necessary assistance in the
protection against disease become the key tasks of
public health. The challenge goes beyond the concern
for relevance and the need to understand local values
and constructions of health and disease in order to
improve communication for better compliance. The
notion of learning from the community con rms that
the community actually has something to contribute.
It re ects an attitude of basic respect for accumulated
knowledge and trusts in that each individual and group
of individuals have abilities, resources and creativity
which are essential for health.
7
One of the ideal approaches could be that the medical
institutions taking direct accountability of health care of
certain areas within their catchments and use the health
facilities within those areas as teaching centres. Lack of
clarity in functional domain of Ministry of Education and
Ministry of Health and Population have been hindering
the colleges in devising appropriate strategy to address
the ethos of community based medical education.
Conclusion and Recommendations
1. Community based practices are essential components
with the speci c aim of developing the student’s
competencies in understanding community health
problems. These later enable students to solve these
problems whilst working with the community. All
eld activities need to be need-responsive, problem
solving, and community oriented. This encourages
students to render services while they learn and
develop clinical and public health management
skills.
2. There is no doubt in the context of Nepal that
community based medical education can be an
ideal endeavour but how it can be practiced in
realistic way? The expectation of the community
has increased in the changing context and they are
refractory to external interferences. Challenges
are multiplying. To provide truthful and effective
community based medical education it is now the
appropriate time to review our current practices and
re-design as per the demand.
3. The means to involve the community actively
and strengthen community health development
endeavours in sustained way to bene t community
is essential. This will facilitate in the health care
developmental endeavour and enrich the medical
institutions, community and boast the moral of
community based institutions working in this eld
collectively.
4. Medical colleges need to be accountable to take
the responsibility of strengthening the health status
of the community of their catchments areas. The
practice of community medicine needs to be done in
an innovative way and the colleges should execute
intervention activities continuously and complement
other institutions working in their areas. To increase
the health status of the community they need to
facilitate and strengthen the governmental and non-
governmental institutions in their catchments areas.
They also need to increase the capacity and utilise
these as their training sites.
5. Medical schools need to continually address on
target areas with continual follow up of the work
and focus on addressing health care needs along
with academic pursuit. The innovative health
interventions need to be designed and applied as
per the reality of the circumstance. In this regard,
governmental institutions, INGOs/NGOs need to
work together sharing the resources and translate
the ethos of community based medical education in
the real sense.
References
1. Solyom AE. Contemporary challenges of
medical education: morality and integrity of
physicians. [cited on 2009 Jan]. Available from:
http://www.ishm2006.hu/scientific/abstract.
php?ID=290.
2. Marahatta SB, Dixit H. Students’ perception
regarding medical education in Nepal. KUMJ.
2008; 6(2):273-83.
3. School of Medical Sciences, Kathmandu
University. Report on Present Status of Medical
Education in Nepal: Need for Twenty-First
Century. Kathmandu: Kathmandu University;
January 2006.
4. Mattock NM, Abeykoon P. Innovative program
of Medical Education in South East Asia.
Regional Publication SEARO. 1993; No 21:29-
40.
5. Hamad B. Community-oriented medical
education: what is it?
Med Edu. 1991; 25(1):16-
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Education: Where we are heading?. KUMJ.
2007;5(2):149-50
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7. Mogedal S. Learning from community;
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    • "It is the curative role that builds trust in the community. The same has not been addressed in similar communications where community posting was being assessed [12, 13]. We quote one of our students verbatim: " We would have benefitted more if we had our own PHC by now. "
    Full-text · Article · Jan 2016
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    • "In the absence of sufficient local public health expertise, there is a persistent dependence on international consultants to manage public health issues, often leading to inequitable, expensive, and uncoordinated development efforts. A community-based approach to medical training has always been an integral part of the Nepalese medical-school curriculum [11,12]; however, the inability of Nepali health professionals to efficiently deal with the recent cholera epidemic in western Nepal, which claimed 301 lives, is an example of the inadequacy of public health training in the country [13,14]. There has been little investment into research on epidemiology, health-information systems, or management [11] and, in contrast to medical education, public health education has received relatively little attention or investment. "
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    • "After the predominant attention paid to health practitioners, there is growing interest in the intra-organizational workings of HCO&S. Such studies adopt the perspective of situational analysis, communities of knowledge and practices, systems of internal knowledge and communication (see e.g. Marahatta et al. 2009;). g. "
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