Family Adoption Program: An NMC-mandated Initiative

Abstract

The National Medical Commission (NMC) of India has introduced the Family Adoption Program (FAP) as a key initiative within the Competency-Based Medical Education (CBME) framework. FAP is designed to reshape medical education by deeply embedding students within communities, providing a platform for experiential learning that enhances their understanding of healthcare challenges beyond the clinical setting. Under the program, medical students adopt families in rural or underserved areas and work with them over an extended period, addressing health needs and fostering a holistic, socially responsive approach to care. This engagement allows students to understand the multifaceted determinants of health—such as social, economic, cultural, and environmental factors—that influence well-being and disease. Through direct interaction with families, students develop a community-centred approach to healthcare delivery, fostering continuity of care and empowering communities in managing their own health. This paper explores how FAP integrates community engagement into medical education, driving both student learning and community health outcomes. It outlines the theoretical underpinnings and practical implementation strategies of FAP, offering a roadmap for medical colleges to successfully integrate this initiative into their curricula. The paper highlights best practices and innovative approaches from institutions, emphasizing the need for institutional ownership, interdisciplinary collaboration, and partnerships with local communities to ensure long-term success. Additionally, it provides insights for scaling FAP nationally, positioning it as a transformative step towards cultivating compassionate, community-oriented healthcare professionals. By fostering deeper connections between medical students and communities, FAP has the potential to improve health equity and transform health care across India.

INTRODUCTION

The World Health Organization (WHO) has recommended that all countries strengthen their primary health care services to more accessible health care, through the reformation of the four pillars that underpin the high quality of primary health care services and education, namely Universal coverage, Person-centred care, Public policy, and Leadership.[1] The Indian healthcare system and medical education are going through a series of innovative stints. These changes must be seen as a promise India made, that we will produce doctors with knowledge, skills, attitudes, and values so that they will function as effective community physicians locally while being relevant globally.

As the medical students of today would be the physicians of tomorrow, the dynamic diversity of healthcare needs coupled with challenges of healthcare delivery calls for newer approaches in medical education to prepare future physicians. Furthermore, with rural areas housing about two-thirds of the total population of India, medical education must provide undergraduate students with a first-hand experience of the living conditions of the people they will encounter during their practice as patients and an opportunity to decipher how the social determinants of health impact health of the people.

Holistic learning experiences have been recognized by the National Medical Commission (NMC) as a vital component in medical education and as a step in this direction, which has advocated a community-oriented medical education in the form of the Family Adoption Program (FAP). Community engagement is a valuable aspect of medical education, fostering a sense of social responsibility, empathy, and a deeper understanding of the community’s healthcare needs.[2] Community engagement is pivotal to providing medical students with a comprehensive learning experience, and FAP is envisaged to be a promising directive with an optimistic resultant outcome of producing community-oriented and socially responsive Indian Medical Graduates (IMG).

The NMC[3] envisions a medical education system that enhances access to quality, affordable medical education, ensuring a sufficient supply of skilled medical professionals across the country. This vision aims to support equitable, universal healthcare, integrating a community health perspective and making medical services accessible to all citizens, in alignment with national health objectives. The Family Adoption Program builds upon a curriculum deeply rooted in community engagement, where students, faculty, and community members collaborate actively throughout the learning process to provide education relevant to community needs.

This position paper attempts to analyse the multiple facets of the NMC-mandated Family Adoption Program that aim at enhancing the educational journey of medical students and the benefits to the community alike.

What is the family adoption program and its rationale?

The road map for the Family Adoption Program has been detailed in the NMC-CBME-2023 and NMC-CBME-2024 guidelines.[4,5] The Community Medicine Department of every college may allot about five families (minimum three) in a village not covered under Rural health training centres, to each of the first MBBS students under the ‘Family Adoption Program’. The student will be responsible for overseeing the health and well-being of the assigned families for three consecutive years. Through this process, the students will gain firsthand exposure to the living conditions, cultural beliefs, lifestyle practices, and common health challenges faced by marginalized communities. This immersive experience will help them develop a deep understanding of the determinants of health in these populations and equip them with the skills to address health issues more effectively when they become practicing doctors.

The Family Adoption Program offers medical students a valuable experiential learning opportunity that impacts both the student and the communities they serve. Over time, this initiative is expected to contribute to improving primary healthcare delivery at local, district, state, and national levels, fostering greater health equity and better outcomes for marginalized populations.[6]

FAP in the context of current medical education and national education policy

The Shrivastava Committee, established by the Government of India in 1975 as the Group on Medical Education and Support Manpower, emphasized that the focus of medical education should shift from producing Indian medical practitioners with excessive emphasis on disease treatment to embracing a sense of complete social responsibility.[7,8] The committee acknowledged the creation of Preventive and Social Medicine Departments as a positive step but expressed concern that medical college field areas were inadequately prepared. They noted that students spent most of their education in teaching hospitals rather than in the community, resulting in a disconnect between medical education and the fundamental health needs of the population.[9]

The necessity to transform the undergraduate curriculum in India has long been emphasized. There has been a demand to abandon the colonial model with its didactic and master–student approach (now even outdated in entire Europe) to a less autocratic learner-centric, skill-based, and more patient/community-centric course. This will give a scope to the students of the twenty-first century to better appreciate the prevalent disease conditions and health problems of the country while giving them a realistic idea of how to take care of the health of the people with limited resources.[10]

The responsibility for implementing and monitoring the FAP lies significantly with the Community Medicine (Preventive and Social Medicine) departments in medical colleges. While clinical medicine primarily focuses on individual patients, community medicine acknowledges the broader determinants that influence the onset of various health conditions. Over time, Community Medicine has been instrumental in promoting a ‘community perspective’, which contrasts with the hospital-centred approach of other disciplines. These departments are uniquely positioned to foster community-based education, which requires flexibility and innovation—the core essence of FAP—rather than the disease-specific, hospital-based education.

‘Unnat Bharat Abhiyan’ (UBA)[11], a flagship program of the Ministry of Human Resource Development of the Government of India, also encourages University students to adopt villages to address development challenges for sustainable development, so that higher education institutions contribute to the social and economic betterment of the community. Faculty and students of higher education institutions are envisioned to understand the rural realities and be part of the village development plan in collaboration with the district administration. National Education Policy, 2020[12] of India, encourages the engagement of students with local communities in the form of community-based projects. Accrediting agencies such as the National Assessment and Accreditation Council (NAAC), and the frameworks like the National Education Policy-2020, emphasize the need for our curriculum to address local, national, and global health needs.

What is the conceptual roadmap for making a change through FAP?

Figures 1 and 2 present a ‘Theory of Change’ vision depicting the pathways through which the family adoption program may result in the desired student-related outcomes and positive transformations in medical education and healthcare. On the proximal side, the theory of change [Figure 1] helps to identify the factors at the organizational level, curricular level, and intra- and interpersonal level which could further enhance the desired outcomes. Fortunately, the recent developments in medical education in India have emphasized several of the related curricular changes identified through this vision.[13,14,15] For the student-related outcomes [Figure 2], the vision is based on the four relationship (4R) model, a framework developed by Paul Worley, which identifies four axes—the clinical axis, the social axis, the healthcare vs evidence axis and the personal axis.[16,17] This framework helps to identify the elements of the Family Adoption Program and depicts the pathways to the desired student-related outcomes along all four axes. As shown in Figure 1, the proposed changes through the Family Adoption Program will not only impact the outcomes related to the Indian Medical Graduate but are also expected, in the medium and long term, to transform the entire landscape of health professionals’ education and healthcare in the country.[18]

Figure 1.

Tri-level alignment for the success of Family Adoption Program; Intra & Interpersonal, Curricular and Organisational (Conceptualised by Dr Subodh Gupta)

Figure 2.

A Theory of Change roadmap for Family Adoption Program

Exploration of best practices in FAP and Lessons learned

The ball has been rolled with the launch of the NMC-mandated Family Adoption Program across 706 plus medical colleges that would rope in over 1,00,000 medical students across the country into the FAP.

A best practice is a technique or method that has consistently proven effective in achieving desired outcomes through experience and research. Documenting and sharing exemplary practices enable the acquisition of insights from lessons learned, refining and adapting strategies and activities through feedback, reflection, and analysis, and implementing more sustainable and impactful interventions. Sharing these practices is essential to facilitate their adoption, ultimately benefiting a larger population [Table 1].

Table 1.

Existing and Emerging FAP Best Practices using Novel approaches

FAP Practices	Novelty/Strengths
Existing Best Practices
A) Mahatma Gandhi Institute of Medical Sciences Sevagram[18,19,20,21,22]     *MGIMS has been implementing the Village Adoption Scheme regularly since 1969 when the first batch of MBBS joined the institute.     *A village is identified from the field practice area for each batch of medical students based on active involvement from the village, population size, proximity to the institution, and availability of necessary amenities for a 2-week residential camp.     *Starts with first-year MBBS students residing in an adopted village for a fortnight when students actively engage with families and do a comprehensive health assessment for each family as well as a community diagnosis. During the period of the camp, the institute extends health services like daily OPDs and basic drugs, and free management of patients referred from the camp to the medical college hospital.     *Students take ownership of the health of adopted families. Following the residential camp, the students visit their adopted village and families once every month till the 7th semester.     *For the follow-up visits, the institute has a list of topics and well-defined activities (including individual as well as group activities) for each topic. The students also participate in health promotion activities in the village.     *The program integrates practical health interventions, research endeavours, and leadership skill cultivation, significantly enhancing students' comprehension of public health and community engagement.     *Formative as well as Summative practical assessments in Community Medicine are conducted in the adopted families; providing an opportunity to assess the soft skills of the students and emphasize on acquisition of skills.	• A well-defined field practice area of 90 villages • Continuous community engagement through community-based organizations (Panchayati Raj Institutions, Village Health Nutrition and Sanitation Committee, Women’s Self-help group and adolescent girls’ groups) • Regular community-based health activities. • Active participation of students in crucial community-based national health research under the guidance of faculty members. • Rich potential to nurture research skills among undergraduates, focusing on transformational initiatives within the community.
Emerging Best Practices
A) SLMCH, Chennai *Community volunteer's role in Family allotment, student safety, guidance in the field area, liaison between students and families and bridging communication gaps. * A family health card with a unique ID was given to each family to follow up at the medical college Hospital.	• Utilising community volunteers in FAP • Issue of Family Health cards
B) AIMSR, Bathinda     *Preparation of framework for Portfolio development for FAP     *Utilizing the portfolio for student learning     *Developing rubrics for portfolio assessment     *Utilizing portfolios for assessment using the rubrics	• Introducing and using Portfolios for learning as well as assessment of FAP for facilitating experiential learning.
C) St. Johns Medical College, Bangalore     *CARE-VIP-MED model     C - Community Choice: Decide whether to implement the program in an Urban or Rural setting.     A - Area Assessment: Tentatively identify potential villages for the program.     R - Regional Reach: Determine which villages fall under the jurisdiction of the local panchayath.     E - Engage Leaders: Approach and collaborate with the Panchayath President to discuss objectives and select program villages.     V - Village Visit: Conduct a Pilot Visit to interact with residents and communicate the program's intent.     I - Informed Selection: Finalize the selection of villages based on pilot visit findings.     P - Public Partnership: Collaborate with panchayath members and key community stakeholders for engagement, including ASHA workers, anganwadi members, waterman, school head master/mistress, dairy Secretary, and community-based organizations (CBOs).     M - Medical Coordination: Notify the PHC Medical Officer of your visits, seek the assistance of the ASHA worker in identified villages, and request generic medicines from the PHC for the medical camp.     *The "CARE-VIP-MED" acronym summarizes the unique process of planning and executing the Family Adoption Program while emphasizing the importance of community engagement and healthcare coordination.	• Creation of a sustainable model, emphasizing active participation and support from local leadership and stakeholders.
D) GCSMCH &RC, Ahmedabad     *Regular follow-up and counselling of family for medication.     *Awareness sessions on role of diet and physical activity in prevention and control of NCDs     *All family members above 30 years screened for Hypertension and Diabetes (RBS)     *All adolescent girls and women in reproductive age screened for Anemia (Hb)     *Opportunistic screening for TB, CKD and Cancers.	• Development of a protocol for tracking health status of family members

#Data was invited via a shared Google link

The expansion and institutionalization of successfully tested best practices requires strategic planning. Despite varied existing constraints in each medical college, it is possible to find an agreement on the development of competencies and anchoring them in medical education based on a common goal.

These developments derive implications for the implementation of practices that can be replicated to effectively cultivate a generation of compassionate and empathetic healthcare professionals who prioritize patient needs and well-being, thereby contributing to the overall improvement of the healthcare system in the country.

What are the recommendations and way forward?

For the Family Adoption Program to achieve the desired outcomes, to ensure its long-term sustainability and to create a suitable ecosystem where it evolves gradually in a much richer program, the following points would be helpful.

1. Beyond the curriculum, factors at the organizational and personal levels are anticipated to play a pivotal role. Our current understanding of pathways to develop crucial elements at the organizational and interpersonal levels is limited. The following approaches involving various stakeholders will prove beneficial:

   1. While the directive from the National Medical Commission mandating implementation of the Family Adoption Program is commendable, the provision of options and flexibility to medical colleges to tailor the program based on their strengths and resources would enhance local relevance and adaptability over time. This approach instils a sense of ownership among medical colleges and other stakeholders, ensuring quality at both organizational and interpersonal levels. It also facilitates customization according to the specific needs of the local community. However, in offering options and flexibility, care should be taken not to compromise the objectives laid out by the NMC

   2. National Medical Commission, other professional bodies, and interested groups should establish platforms for dialogue on the Family Adoption Program, encouraging innovation and research. Training programs for academic heads and faculty members can significantly enhance the program’s quality.

   3. Medical colleges should view the Family Adoption Program not merely as a mandatory activity outlined by the NMC guidelines but as a gradual process. Working towards enhancing essential factors at both organizational and personal levels will maximize the desired student outcomes.

2. The Family Adoption Program serves a dual purpose; enriching student learning on one hand and improving access to healthcare services as well as fostering community empowerment for health on the other. When designing this program at the medical college level, it is crucial to establish a ‘win-win’ situation. Given India’s diversity, customizing the ‘win-win’ approach for each setting becomes imperative.

3. The guidelines issued by the National Medical Council stipulate that villages chosen for the family adoption program should lie outside the field practice area of the medical colleges. Nevertheless, recognizing villages within the field practice area could yield unique benefits for both student learning and the villages. This approach would offer medical colleges a distinct advantage in achieving enhanced community mobilization and improved access to healthcare services. By demonstrating the impact of community-based approaches, these medical colleges can effectively contribute to advancing community health outcomes in the identified villages and enriching student learning.

4. Establishing a robust partnership between medical education and the public health system is a crucial determinant for the success of the family adoption program.

   1. The National Medical Council should meticulously outline the role of the State Directorate of Health Services concerning medical colleges in the family adoption program, mirroring the clarity established for other initiatives such as Ayushman Bharat Health and Wellness Centres or the District Residency Program. Similarly, comprehensive national-level guidelines for partnerships with the Department of Women and Child Development and other related sectors should be formulated.

   2. Medical colleges should proactively take steps to fortify partnerships at the district and sub-district levels with the health sector, Integrated Child Development Services (ICDS), and other associated departments.

5. Human resources, along with other logistical considerations, play a vital role in the effective implementation of the family adoption program. It is pertinent for the National Medical Commission to revise the minimum standard requirements concerning field staff for medical colleges, guaranteeing sufficient human resources and logistical support. Within medical colleges, both administrative and academic leadership must accord priority to the family adoption program and allocate ample resources, including human personnel. This provision of adequate human resources is essential to ensure robust student support and guidance throughout the family adoption process, thereby maximizing the program’s learning impact. Additionally, emphasis should be placed on involving faculty and staff from departments other than Community Medicine.

6. Medical colleges should adopt a multi-sectoral and multi-disciplinary approach, ensuring active participation from all departments within the institution. A robust partnership with the healthcare delivery system, along with collaboration with other related sectors, is essential. Additionally, a concerted effort in intensive community mobilization will be required for successful implementation as well as for ensuring the desired outcomes from the family adoption program.

7. Integrating student assessments within community settings will enhance student engagement in the family adoption program.[19] The community serves as an authentic setting for assessments, allowing students to be observed while carrying out tasks in real healthcare settings. Assessing students in the community and other authentic settings can complement and fill gaps in the assessment methods typically employed in medical institutions. Furthermore, community-based assessment offers unique advantages in evaluating the personal values and professional skills of students.

8. The National Medical Commission (NMC) and other professional bodies should strategically focus on continuous process evaluation, documenting best practices, and promoting innovations and research within the framework of the family adoption program. Additionally, a comprehensive program evaluation plan should be developed to assess the outcomes of the Family Adoption Program in the long term.

9. The lessons learnt from the Family Adoption Program for medical students may be extended to other health professional courses. In addition, exploring the feasibility of integrating the Family Adoption Program (FAP) with nursing and/or other allied health sciences courses should be considered, particularly based on the co-location of other courses.

10. The purpose of this community-based teaching program should be to ensure students’ meaningful engagement with the local community for their sensitization to community problems through service learning. To make this engagement meaningful for both students and the community, one requires careful session planning, set visit plans, and due consideration of the resources in terms of time, manpower, transport, and money.

11. The FAP should be owned by the college. The authors take a stand that this initiative should be owned by the college, and coordinated by the Department of Community Medicine with participation from all other Departments by sending their faculty on the visit or for provision of services. We have to note that such changes occur over a period of time due to the long-term vision and commitment of institutional leaders.

The Family Adoption Program for MBBS students can galvanize medical education in India if planned carefully and implemented efficiently. The holistic, patient-centred learning experience received by the students through FAP will enable the outgoing healthcare professionals to be in sync with the healthcare needs and delivery system.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.