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Print version ISSN 0042-9686
Bull World Health Organ vol.82 n.2 Genebra Feb. 2004
Delays in legislation slow the progress of CME in India
Bishahka de Sarkar; Sanjay Kumar
Indian medical associations say their doctors desperately need continuing medical education (CME) to keep them up to date with the latest drugs, equipment and medical practices but legislation to make this a requirement has made little progress.
The Medical Council of India is campaigning for CME to be made compulsory, as it is in the UK and some US states, for the country's 615 000 registered doctors and has proposed a draft amendment to a law that would standardize medical practice across the country while making sure it is up to date with the latest developments.
If passed into law, mandatory CME for registered doctors in India could set a precedent for other developing countries but some Indian doctors say their medical associations have failed to lobby hard enough for this and lawmakers have been slow to respond.
"There is resistance to change by [health] professionals who lack the opportunity for undergoing good quality CME, and lack incentives as well as motivation for attending CME programmes," said Dr P.T. Jayawickramarajah, Coordinator at the WHO's Regional Office for South-East Asia in New Delhi.
Other doctors in India fear that without CME courses, lack of up-to-date knowledge can endanger lives and perpetuate out-moded practices. Umesh Kakrania of SPARSH, a support group for people with HIV/AIDS, said that many Indian doctors were still recommending single or double anti-retrovirals rather than triple combinations which are standard. "Several premature deaths have occurred due to this sad situation," Kakrania said.
Kakrania said that many doctors, paramedical and nursing staff in India still suffered from the "anti-AIDS phobia" of the past and urgently needed to improve their basic medical education. He said many medical staff still refuse to touch HIV positive patients.
Dr Shekhar Saxena, an Indian physician who works at WHO in Geneva, said that enacting a legislation to make CME mandatory is a necessary but not sufficient requirement for delivering quality knowledge and skills to practicing doctors in India.
"Allocation of substantial funds and professional resources will be needed to really make the system work and it is important that pharmaceutical companies are not allowed to dictate this agenda based on their financial power," said Saxena.
Despite the lack of legal incentive for doctors to attend regular refresher courses, CME has been catching on in India over the last three years partly due to the efforts of regional medical associations.
Dr Puneet Bedi, a gynaecologist in Delhi, however, believes that doctors' attitudes will change as more doctors in India realize they must keep up to date with the latest medical practice, but progress is slow. "We are moving extremely slowly in promoting CME," said Dr B.V. Adkoli of the All India Institute of Medical Sciences in New Delhi.
The Delhi Medical Council, which represents 24 000 doctors in the capital, made it mandatory two years ago for members to complete 100 hours of CME every five years before they can re-register as doctors.
CME programmes have also been held in Belgaum, Mangalore, Madurai, Manipal and Tirunelveli in the south, Dharamshala, Aligarh and Muzaffarnagar in the north, Bhopal, Nagpur and Jaipur in the west and Cuttack, Patna and Guwahati in the east but doctors in many rural areas are still missing out as they have little or no access to such courses.
CME is a requirement for the regis-tration of health professionals in many developed countries, such as the United States, but CME opportunities are limited in the developing world because of the lack of legal or other incentives, according to a study called Promoting Rational Use of Medicines published in September 2002 by WHO's Essential Drugs and Medicines Policy Department.
Last year, the Medical Council of India established a code of ethics stating that members should complete 30 hours of CME every five years in order to re-register as doctors, but only about 20% of India's doctors follow this as it is not legally binding.
Now the Medical Council of India wants the Indian parliament to enshrine this principal in law by amending the Indian Medical Council Act of 1956 that governs medical practice across the country. In September 2002, the Indian daily newspaper, The Times of India, reported that the proposal was "gathering dust."
"We want registration to be for a period of five to seven years with re-certification subject to CME attendance," Dr A.R.N. Setalvad, Secretary of the Medical Council of India, adding: "The proposal is still under consideration and nothing can be done until the act is amended by the parliament". It was unclear when the draft proposal would come up for review or be debated, and whether it had a chance of being passed into law.
Some doctors say that one solution to the impasse could be for more regional medical associations to take the lead, like the Delhi Medical Council, and make CME a requirement for re-registration of doctors and other health professionals. This, they hope, could have a knock-on effect across the country.
The response to requiring doctors in the Indian capital to undergo CME re-training has been positive. Dr S.K. Khattri, Secretary of the Delhi Medical Council, said the Council had conducted 316 courses since the start of its CME programme in mid-2000.
CME courses in India are funded by a wide range of organizations: the Medical Council of India, which says it spends U$ 330 000 on CME a year, international organizations such as UNICEF, private firms such as Indian generic drugs companies, as well as the Indian Ministry of Health.
Amit Sengupta of the Delhi Science Forum, a New Delhi-based body for scientific research and advocacy, said that because of low literacy levels and poor awareness of good medical practice at the community level, there is little pressure from patients to motivate doctors to participate in CME programmes, despite what he referred to as the "dismal quality" of the medical service.
"Most people see the medical professional as someone next to God, so there is very little questioning of norms or practice," Sengupta said.