Insights into Editorial: Capacity building for primary health care

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Insights into Editorial: Capacity building for primary health care


Context:

A contentious element of the National Medical Commission (NMC) Bill 2017 — an attempt to revamp the medical education system in India to ensure an adequate supply of quality medical professionals —proposes a joint sitting of the Commission, the Central Council of Homoeopathy and the Central Council of Indian Medicine.

This sitting may decide on approving specific bridge course that may be introduced for the practitioners of Homoeopathy and of Indian Systems of Medicine to enable them to prescribe such modern medicines at such level as may be prescribed.

What does the National Medical Commission, 2017 Bill seek do to?

The 2017 Bill sets up the National Medical Commission (NMC) as an umbrella regulatory body with certain other bodies under it. 

  • The NMC will subsume the MCI and will regulate the medical education and practice in India.   
  • Under the Bill, states will establish their respective State Medical Councils within three years.  These Councils will have a role similar to the NMC, at the state level.
  • There will be a uniform National Eligibility-cum-Entrance Test for admission to undergraduate medical education in all-medical institutions regulated by the Bill.
  • The Under-Graduate Medical Education Board (UGMEB) and the Post-Graduate Medical Education Board (PGMEB): These two bodies will be responsible for formulating standards, curriculum, guidelines, and granting recognition to medical qualifications at the under-graduate and post-graduate levels respectively;
  • The Medical Assessment and Rating Board: The Board will have the power to levy monetary penalties on institutions which fail to maintain the minimum standards as laid down by the UGMEB and the PGMEB.  It will also grant permissions for establishing new medical colleges.
  • According to the Bill, the Ethics and Medical Registration (EMR) Board shall maintain a separate National Register –including the names of licensed AYUSH practitioners.
  • Functions of the NMC include:
  • Laying down policies for regulating medical institutions and medical professionals,
  • assessing the requirements of human resources and infrastructure in healthcare,
  • ensuring compliance by the State Medical Councils with the regulations made under the Bill, and
  • Framing guidelines for determination of fee for up to 40% of the seats in the private medical institutions and deemed universities which are governed by the Bill.
  • Perhaps the most controversial provision of all is for a bridge course allowing alternative-medicine practitioners to prescribe modern drugs. One motivation could be to plug the shortfall of rural doctors by creating a new cadre of practitioners.

Why do we need more trained practitioners?

The debates around this issue have been ranging from writing-off the ability of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners to cross-practise to highlighting current restrictions on allopathic practitioners from practising higher levels of caregiving.

However, these debates miss the reality: which is a primary health system that is struggling with a below-par national physician-patient ratio (0.76 per 1,000 population, amongst the lowest in the world) due to a paucity of MBBS-trained primary-care physicians and the unwillingness of existing MBBS-trained physicians to serve remote/rural populations.

Urban-rural disparities in physician availability in the face of an increasing burden of chronic diseases make health care in India both inequitable and expensive.

Therefore, there is an urgent need for a trained cadre to provide accessible primary-care services that cover minor ailments such as fever, upper respiratory tract infections, gastrointestinal conditions (diarrhoea, acidity), urological conditions; health promotion services; risk screening for early disease detection and appropriate referral linkages, and ensure that people receive care at a community level when they need it.

Arguments in favour of Bridge Courses and cross-prescription

The issue of AYUSH cross-prescription has been a part of public health and policy discourse for over a decade, with the National Health Policy (NHP) 2017 calling for multi-dimensional mainstreaming of AYUSH physicians.

  • There were 7.7 lakh registered AYUSH practitioners in 2016, according to National Health Profile 2017 data. Efforts to gather evidence on the capacity of licensed and bridge-trained AYUSH physicians to function as primary-care physicians have been under way in diverse field settings.
  • The 4th Common Review Mission Report 2010 of the National Health Mission reports the utilisation of AYUSH physicians as medical officers in primary health centres (PHCs) in Assam, Chhattisgarh, Maharashtra, Madhya Pradesh and Uttarakhand as a human resource rationalisation strategy.
  • In some cases, it was noted that while the supply of AYUSH physicians was high, a lack of appropriate training in allopathic drug dispensation was a deterrent to their utilisation in primary-care settings.
  • Similarly, the 2013 Shailaja Chandra report on the status of Indian medicine and folk healing, commissioned by the Ministry of Health and Family Welfare, noted several instances in States where National Rural Health Mission-recruited AYUSH physicians were the sole care providers in PHCs and called for the appropriate skilling of this cadre to meet the demand for acute and emergency care at the primary level.

Way Forward

Keeping in view the current realities prevailing in the country, the Act has introduced a system under which the Commission and the heads of the councils of Ayush can design bridge courses legalising  Ayush practitioners to prescribe allopathy medicines.

 

Capacity-building of licensed AYUSH practitioners through bridge training to meet India’s primary care needs is one of the multi-pronged efforts required to meet the objective of achieving universal health coverage set out in NHP 2017.

Current capacity-building efforts include other non-MBBS personnel such as nurses, auxiliary nurse midwives(ANM) and rural medical assistants, thereby creating a cadre of mid-level service providers as anchors for the provision of comprehensive primary-care services at the proposed health and wellness centres.

Further, the existing practice of using AYUSH physicians as medical officers in guideline-based national health programmes to ensure uninterrupted care provision in certain resource-limited settings hold promise.

Hence ensuing discussions will be well served to focus on substantive aspects of this solution: design and scope of the programme, implementation, monitoring and audit mechanisms, technology support, and the legal and regulatory framework.

In the long run, a pluralistic and integrated medical system for India remains a solution worth exploring for both effective primary-care delivery and prevention of chronic and infectious diseases.