A recent paper published in the National Medical Journal of India has emphasised the need to introduce a cadre of mid-level healthcare providers (MLHPs) into the health systems to compensate for physician shortages.
Authored by Soham Bhaduri, a public health specialist and independent researcher, the paper states that the MLHP model can create win-win combinations within healthcare that can benefit patients, doctors, healthcare financiers and the society at large.
To compensate for physician shortages, several countries around the world have introduced a cadre of MLHPs into their health systems to shoulder many of the conventional responsibilities of a physician. However, In India, mainstreaming of MLHPs has time and again been met with resistance from organised medicine.
“Policy-makers will need to work towards finding greater acceptance of MLHPs among existing health occupations, by demonstrating their complementary role in patient care and assuaging long-established concerns such as quackery. Coupled with professional practice models that ensure long-term growth and career advancement, MLHPs can bolster India’s journey to achieve and sustain universal health coverage,” Dr. Bhaduri says in the paper.
Huge shortage of doctors in rural India
According to the Health Dynamics of India (Infrastructure and Human Resources 2022-2023) report released in September this year by the Union Ministry of Health and Family Welfare, community health centres (CHCs) in rural India face a nearly 80% shortfall of specialists as of March 31, 2023.
The report, previously published as Rural Health Statistics, showed that of the required 21,964 specialist doctors in rural CHCs, only 4,413 were available up to March 2023, indicating a shortfall of 17,551 (79.9%).
Across 5,491 rural CHCs in 757 districts across the country, there is a requirement of 5,491 surgeons, physicians, gynaecologists, and paediatricians each in these facilities. However, the report showed that rural CHCs experienced a shortfall of 4,578 surgeons (83.3%), with only 913 surgeons in position against the required 5,491.
Similarly, a deficit of 4,078 gynaecologists (74.2%) was recorded in rural CHCs, with only 1,442 in position against the 5,491 required, while a shortfall of 81.9% was recorded among physicians, with only 992 in place. A similar trend was observed among paediatricians, with only 1,066 in place at rural CHCs, leading to a shortfall of 80.5%.
And this is not a problem restricted to a few States in the country. Even States that routinely perform well on health indicators face these issues. Take the example of Karnataka, for instance, the vacancy of doctors/medical officers in rural PHCs here has increased from 196 in 2005 to 340 in 2023.
In terms of specialists at the CHCs, of the required 758 specialists, only 451 posts are sanctioned. Of these, 178 posts are vacant resulting in a shortfall of 455 specialists in Karnataka’s rural CHCs, according to the report.
In fact, shortage of manpower is a perennial problem in State-run hospitals. In 2022, the Karnataka Health Vision Group had pointed to wide disparities in distribution and availability of specific and specialised manpower in government hospitals. It had recommended a clearly defined Health Human Resources (HRR) policy.
Case for MLHPs
Speaking to The Hindu, Dr. Bhaduri said the paper explored a fresh case for MLHPs in India in view of some recent developments and the probable future contours that Indian healthcare is likely to assume.
“Evidence shows that MLHPs can, under certain circumstances, provide care of an equivalent quality and safety to that of physicians at lower overall costs, across a range of settings. They have also been found to fare equally well or better in terms of patient satisfaction and trust, apart from evident contributions to improving healthcare access and utilisation in underserved and rural areas. Evidence also indicates that MLHPs are less prone to emigration and more likely to remain in underserved areas — two prominent problems that have perennially plagued health systems when it comes to physicians,” he said.
In India, both Central and State governments have from time to time conceived of bridge courses in allopathy to address the shortage of doctors in rural areas. In 2010, a proposal to start a shortened medical degree in rural healthcare was proposed, which was backed by the Planning Commission. States such as Assam and Chhattisgarh have successfully deployed State level MLHP cadres to improve access to primary healthcare in rural areas. However, attempts to mainstream MLHPs have time and again been resisted by organised medicine, mainly on the premises that they can worsen quackery and amount to discriminatory treatment with rural citizens, Dr. Bhaduri said.
Corroborating Dr. Bhaduri’s views, former NIMHANS director G. Gururaj, who headed Karnataka’s Health Vision Group, said MLHPs can bolster India’s journey to achieve and sustain Universal Health Coverage (UHC).
Stating that some recent policy and legislative measures have offered renewed hope for a systematic revival of MLHPs in India, Dr. Gururaj said the Comprehensive Primary Health Care (CPHC) guidelines under the Central government’s flagship Ayushman Bharat Mission make provisions for the deployment of community health officers (CHOs) in sub centres. They can provide an expanded set of primary care services and refer them to doctors for further treatment, he said.
“As MLHPs are based in health sub centres, close to the community, continuity of care is ensured for patients. They are not supposed to diagnose a condition/disease but provide preventive and promotive care while ensuring patients already diagnosed by doctors are attended to appropriately, especially with follow-up care. They work in close coordination with ASHA workers and Auxiliary Nurse Midwives (ANMs) and have a good understanding of the community,” he said, adding that MLHPs can make a probable diagnosis but not a definitive diagnosis. “There will not be any overlapping of their functions with doctors,” Dr. Gururaj pointed out.
Legitimising quackery?
The Indian Medical Association (IMA) however, has been opposing introduction of MLHPs claiming that it will only legalise quackery in the country.
“This is nothing but quackery. Assigning MLHPs to rural areas amounts to dispensing discriminatory treatment to the rural population. Will these policy-makers agree to be treated by a MLHPs?” asked R. V. Asokan, IMA national president.
On the shortage of doctors in rural areas, Dr. Asokan said there is an adequate availability of medical professionals. “According to the former Union Health Minister Mansukh Mandaviya’s statement in the Lok Sabha in February this year the doctor-population ratio in the country is 1:834 which is better than the WHO standard of 1:1000. According to his statement, there are 13,08,009 allopathic doctors registered with the State medical councils and the National Medical Commission (NMC) as of June, 2022,” he said.
Asserting that there has been no recruitment of doctors through public service commissions for the past 10 to 15 years, Dr Asokan said: “The government is only appointing doctors on an ad hoc basis through the National Health Mission (NHM) and paying them around ₹30,000 monthly. Doctors are made to sign bonds, which is nothing but slavery. It is wrong to say doctors are not ready to work in rural areas when there is no permanent recruitment,” he asserted.
Published – November 07, 2024 05:30 pm IST
