Mumbai: The acute shortage of qualified medical professionals in rural India may impact the relaunch of 150,000 health sub-centres and primary health centres (PHCs) as “health and wellness centres” under Ayushman Bharat Yojana, the national health scheme launched on September 23, 2018.

A lesser known part of the health insurance programme, also called Modicare, comprise health and wellness centres that will have a critical role in controlling the growing burden of non-communicable diseases in India. They will also offer maternal and child health services.

The problem is that sub-centres, run by a team of an auxiliary nurse midwife, a male multi-skilled health worker and health assistants, are short of staff while primary health centres do not have enough doctors:

  • Of the 156,231 sub-centres in India, 78,569 were without male health workers, 6,371 without auxiliary nurse midwives and 4,263 without either, according to Rural Health Statistics, 2017.

  • PHCs require 25,650 doctors across India to tend to a minimum of 40 patients per doctor per day for outpatient care, as per Indian Public Health Standards (IPHS). If these standards are met, 1 million patients could be benefit everyday. But with a shortage of 3,027 doctors, 1,974 PHCs are without doctors. This means that 12%, or 121,080 patients, go without access to primary health care every day.

Healthcare in India’s villages is a three-tiered structure under the National Rural Health Mission (NRHM)--sub-centres, primary health centres and community health centres.

Sub-centres are at the forefront, covering 5,000 people in the plains and 3,000 in hill or tribal areas. PHCs are equally important for the Ayushman Bharat Yojana to succeed because they are the first link to a consultation with a medical doctor and act as referral points for specialist consultations at community health centres.

Strengthening both the PHCs and sub-centres will ease the burden on secondary (district hospitals and block community health centres) and tertiary health institutions (specialist and super-specialist services in hospitals-cum-medical colleges). Failure to find enough doctors will also set back universal health coverage as envisioned by the successive National Health Policies in 2002 and 2017.

Distribution of health professionals skewed in favour of cities

Seventy percent of India’s population lives in villages and 30% in urban areas. But the distribution of health workers leaves rural India with little access to healthcare--60% of the country’s 2-million strong health workforce caters to urban India, only the remaining 40% services villages, as per data from a 2016 World Health Organization (WHO) report.

There is another issue the proposed centres will have to deal with: Health-workers practising in both urban and rural areas of India are not adequately qualified, as per the WHO study. Among urban and rural allopathic doctors, only 58% and 19% doctors, respectively, were medically qualified. As for nurses and midwives practising in rural areas, only 33% have studied beyond secondary school and 11% have medical qualification, the report estimated.

A perception survey of patients who visited healthcare facilities more than once showed that 43% patients, on average, across four states were not satisfied with the medical treatment provided by the health facilities. Of the patients surveyed, 34% complained of staff absenteeism, 32% of shortage of medicines 13% of long waits; 3% said centres were shut, 2% claimed that there were no facilities at all and the remaining 5% alleged different acts of corruption, according to the 2011 report by the High Level Expert Group on Universal Health Coverage.

Low access to public healthcare means reliance on private practitioners

A potential area of concern for the new wellness centres could be the reliance of rural patients on non-degree allopathic practitioners (NDAPs)--practitioners without an MBBS--according to a study carried out in Uttar Pradesh and Bihar.

Studies in rural Karnataka, Andhra Pradesh and Odisha have shown reliance on private practitioners for multiple reasons. The biggest of these is the lack of easy access to public health facilities: 73% sub-centres were more than 3 km from patients, 28% sub-centres and 20% PHCs were not accessible by public transport, concluded an IndiaSpend analysis of a Comptroller and Auditor General report.

The easy availability and proximity of an NDAP allowed for faster consultation, according to this 2014 study carried out in north India. “Embedded in the community, the NDAPs have adapted their services to people’s needs, preferences and economic capabilities”, making them the preferred resource for “all-in-one” services, the study said.

Why qualified medical professionals avoid rural India

Retention of doctors in rural areas is a major challenge which Ayushman Bharat is yet to confront: A 2011 study funded by the World Bank and the UK department of international development found that 39% medical providers in PHCs in 19 major states were counted “absent”.

Poor living and working conditions, irregular drug supply, weak infrastructure, professional isolation and the burden of administrative work--these are some of the challenges faced by doctors on rural postings, stated a 2017 study by the Public Health Foundation of India.

As of 2018, India has 497 medical colleges registered with the Medical Council of India that together offer an intake capacity of 60,680 seats for MBBS. Trends in India, as well as other BRICS nations such as South Africa, suggest that most doctors prefer to sign up for hospital-based specialisations in urban areas than get into general practice at PHCs, a 2015 study published in Human Resources for Health observed.

To address this, policy frameworks in several states have mandated compulsory rural service of 1-5 years during postgraduate medical studies. Further, some states require medical officers to practise medicine in rural areas for a particular period after postgraduate studies.

Mid-level health providers are ideal for wellness campaign: Experts

Mid-level health providers could be the solution to the shortage of doctors in rural areas, according to this report of a national consultation on strengthening rural healthcare, 2018.

“A key challenge that India faces is that even after diagnosis, people continue to use health care services in secondary and tertiary settings, for conditions which can be managed at the primary care level,” said Chandrakant Lahariya, the national professional officer, Universal Health Coverage, WHO. “Mid-level service providers could here help in promoting and continuing to provide primary health care.”

The proposed health and wellness centres, under Ayushman Bharat, will have teams led by mid-level health providers. These could be nurse practitioners, auxiliary nurse midwives or physicians with a short period of training who can aid doctors.

However, this has been a continual site for debate. Upon the release of the National Medical Commission Bill, which sought to introduce a bridge course for AYUSH practitioners so they could practise modern medicine, the Indian Medical Association expressed its reservations about under-qualified practitioners of three kinds. These were those “with no qualification whatsoever, practitioners of Indian medicine (Ayurvedic, Sidha, Tibb, Unani), homeopathy, naturopathy, commonly called AYUSH, who are not qualified to practice modern medicine (allopathy) but are practicing modern medicine; practitioners of so called integrated medicine, alternative system of medicine, electro-homeopathy, indo-allopathy etc. terms which do not exist in any Act”.

But a 2010 study conducted by the Public Health Foundation of India, National Health Systems Resource Centre and State Health Resource Centre of Chhattisgarh was more optimistic about the potential role for mid-level practitioners.

In Chhattisgarh, rural medical assistants (RMAs), a special cadre of health providers trained for three-and-a-half years and equipped with one year of internship, were inducted into the state’s health workforce to fill the gaps created by vacancies for medical officers in PHCs. In 2017, there was a shortfall of 43% doctors (444 doctors in position of a required 785 doctors in PHCs) in Chhattisgarh.

A medical officer with an MBBS and an RMA with a three-year diploma were seen to be equally competent in providing primary health care, the study observed.

In fact, RMAs performed the best in terms of prescribing drugs. The largest proportion of “effective” prescriptions for malaria were written by RMAs (64%); AYUSH doctors (57%) and RMAs (10%) also wrote “better” prescriptions than medical officers for diarrhoea.

Overall, average perceived quality scores were highest for RMAs (85%), followed by medical officers (84%), AYUSH medical officers (80%) and paramedicals (73%).

“Mid-level healthcare providers (MLHPs) are extremely helpful in delivering a range of identified health services, especially preventive and promotive services,” said Lahariya. “India contributes to more than two-thirds of the global burden of non-communicable diseases. Here, the role of the MLHPs becomes even more important.”

Only complications arising from health conditions such as hypertension and diabetes that affect a large number of Indians need specialist care, he pointed out. “Mid-level service providers could be involved in the delivery of preventive and promotive health services and controlling the epidemic of diabetes and hypertension and saving the cost in future from related complications,” he said. “Many African countries have mid-level service providers who impart basic prescriptions and are the standards of care.”

Doctors trained in generalist practice might be better equipped for public healthcare

Another way to increase the presence of doctors in rural India could be to train them in generalist environments, said this report by Academy of Family Physicians of India and World Organisation of Family doctors (WONCA).

“Ninety percent of common problems that affect the community can be handled by a family physician,” said Raman Kumar, president of the Academy of Family Physicians of India. “With medical advancement and a shift towards a privatised medical industry in cities, hospitals are visited for specialised consultations even for smaller reasons like a headache and running nose. Waiting time for a consultation increases and since these services are expensive, people often don’t get access to healthcare and then refer to pharmacies for self-medication or non-degree allopathic practitioners.”

The reliance on pharmacies makes a big dent in family budgets in India. Pharmacies accounted for 52% of the out-of-pocket expenses incurred for buying medicines: Eighteen times more than the expenses incurred in general government hospitals (3%), more than two times the expenses in private general hospitals (22%), as per the household health expenditures in India report released in 2016.

General practice is a specialisation in developed countries like the US and UK, Kumar pointed out. “In India, most graduates are taught in hospital-based, specialist settings and then we expect them to work in a community,” he said. “There will have to be separate departments of family medicine in medical colleges for students and professionals to be introduced to a generalist approach.”

By 2030, India will need to create 15,000 seats for family medicine practitioners, according to a need-assessment report on tertiary care institutions.

(Chhetri, a graduate of Lady Shri Ram College for women, is an intern with IndiaSpend.)

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Devyani Chhetri