Why we need community health providers
Are community healthcare providers needed, but unwanted? The controversy over the provision to provide limited licence to practice allopathic medicine, in the National Medical Commission (NMC) bill, unleashed an outcry of “quackery” from the medical professionals. It is essential that we consider who these healthcare providers are, and what role they can play in strengthening our health services. A look at global experience and the chequered history of mid-level health care providers in India will help.
An ideal health workforce is multilayered and multi-skilled, with complementary roles delivering competent, comprehensive, continuous and compassionate care. Doctors and nurses are most identifiable, but a variety of allied health professionals and community health workers are also integral. Among doctors, there are basic and specialist doctors. Among nurses, there are basic nurses, midwives and advanced nurses. A wide array of allied health professionals exist, from radiographers and optometrists, to lab technicians to physiotherapists and so on. Two other categories have been added across different countries, to meet growing but unmet healthcare needs. These are the community health workers (CHWs) and the mid-level healthcare providers.
Several developing countries have deployed CHWs, under different names but with the same intent — providing basic health services at home or close to home. CHWs also act as community mobilisers and trusted links to the organised health services. Ethiopia employed “health extension workers” to provide better antenatal care and reduce maternal mortality. Rwanda has recorded the sharpest fall in maternal mortality in the past 25 years, by deploying CHWs to link communities to nurse-run primary healthcare facilities. Swasthya Sebikas and Swasthya Kormis have strengthened primary healthcare in Bangladesh. Thailand has CHWs designated as village health volunteers and village health communicators. Brazil’s family health teams, too, have CHWs as an important component. India started deploying CHWs initially as mitanins in Chhattisgarh, and later built a nationwide army of accredited social health activists (ASHAs) as part of the National Rural Health Mission.
Mid-level health workers are a category of care providers who are more skilled and qualified than CHWs. This is a concept that emerged when even high income countries recognised that some of the functions that a doctor is traditionally expected to perform can be delivered by skilled persons with a lower level of training. Categories such as nurse practitioners, nurse anaesthetists and physician assistants grew in the United States. These drew on the experience of the Civil War and the Second World War when a shortage of doctors led nurses and paramedics to step in and perform. Formal training programmes, accreditation and role definition followed. Presently, nurse practitioners are a well-defined category in the US, New Zealand and Australia. Apart from shortages of doctors in some regions, the rising costs of healthcare also catalysed the emergence of mid-level healthcare providers.
The Indian experience of creating these categories has been fraught with hesitation and hurdles. Even the National Health Policy (NHP) of 2017 recognises this need, but progress has been slow and contentious. Chhattisgarh initiated a three-year graduate training programme (Diploma in Modern and Holistic Medicine) for creating a cadre of rural medical assistants. They were shown to be as capable as doctors in delivering some of the primary care services. Despite several name changes, the conflict between medical professionals and the aspirations of the new graduates resulted in an identity crisis that finally led to closure of the programme. Assam is the only state where such a course is presently run (Diploma in Medicine and Rural Health Course). On the other hand, the category of Physician Assistants (PAs) has taken root in some southern states and West Bengal, through a 4-year graduate course run by universities. They mostly perform duties under the supervision of doctors in hospitals but have the potential for delivering preventive and promotive services in primary care settings.
Seven years ago, the Union health ministry initiated a proposal to train and employ mid-level healthcare providers through a three-year programme modelled on the Chhattisgarh course, to meet the needs of primary care. The Medical Council of India (MCI) developed a curriculum which was a compressed MBBS programme (“MBBS Bonzai”) more suited to hospitals than to primary care. The MCI, however, balked at regulating this course because it violated its mandate to deal only with medical education.
So, the health secretary of the time, PK Pradhan came up with an unorthodox solution. The course was labelled as B Sc(Public Health), and the National Board of Examinations (NBE) was asked to deliver it through its affiliated hospitals and colleges. The NBE, which was hitherto mandated to deliver only postgraduate medical education, accordingly modified its articles of association to include undergraduate and postgraduate courses in public health. A group of experts, which included VK Paul (presently a member, NITI Aayog) prepared the curriculum for the course. However, the proposal lost steam after Pradhan’s tenure ended.
The proposal resurfaced after NHP 2017 called for a BSc in community health and “bridge courses” for developing mid-level healthcare providers. The proposal to provided bridge courses to AYUSH practitioners of the Indian systems of medicine seems to have retreated in the face of fierce opposition from the Indian Medical Association (IMA). However, the inclusion of community health providers (CHPs) in Section 32 of the recently passed National Medical Commission (NMC) Bill has reignited the debates on the qualifications, competencies and functions of these mid-level providers.
The concerns about this provision in the NMC arise because it was an abrupt insertion into the original bill that went before the Parliamentary Standing Committee on Health in early 2019. The courses prescribed, the institutions which will deliver them, the competencies that will be promoted and the nature of functions they are expected to perform are not clear at this stage. Only the role of the NMC in issuing a limited license is described, with ambiguity on when, where and how much medical supervision is required or autonomy is permitted. The blurred lines between NMC (which regulates undergraduate and postgraduate medical education through medical colleges) and this new cadre are agitating the organised medical profession.
India needs mid-level healthcare providers in several forms — nurse practitioners, physician assistants and community health providers — to fill the vast gaps of access and quality in our health services. They are especially required for primary care. Perhaps it is best to diffuse the controversy over CHPs by bringing them under the purview of the Allied Health Professionals Bill which is due to go before Parliament. The CHPs may not fit well into the NMC but surely they can be accommodated as allied health professionals. That may bring accord between the government and the medical profession.
Srinath Reddy is president, Public Health Foundation of India, and author of Make Health in India: Reaching a Billion Plus
The views expressed are personal