Healthcare by Non Doctors; Just what the doctor ordered

Prof (Dr) K Srinath Reddy, President, PHFI, exhorted fellow doctors to cede space

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New Delhi: Dr K Srinath Reddy, President, Public Health Foundation of India (PHFI), has called out his fellow doctors to cede space to non- doctor health workers to deliver a strong programme of primary healthcare to achieve Universal Health Coverage set under Sustainable Development Goals (SDG).

In his India International Centre (IIC) talk on ‘Healthcare by Non-Doctors: An Underused Resource’ on May 7, Dr Reddy coaxed doctors to be amenable to task shifting including limited diagnosis and prescription rights to non doctors. Quoting studies and outcomes all over the world in a good measure, Dr Reddy did not mince words saying competencies should not be sidestepped in the name of qualifications. As goal of Universal Health Coverage (UHC) in India is close to his heart, Dr Reddy bit the bullet; risking wrath of trained doctors who are fiercely guarding their turf. Dr Reddy expressed hope that technology would enable efficient and safe task sharing. The talk was chaired by K N Srivastava, Director, IIC.

Underlining critical shortage of healthcare providers in India, Dr Reddy, a globally renowned health policy expert, made a strong case for use of non doctor resource in turning around primary healthcare in the country. He said empowering them is the best option to fill the gaps. Dr Reddy quoted studies to show that in some cases outcomes have been found even better when tasks were assigned to non doctors. In his scheme of healthcare by non doctors, nurses and midwives constitute the most valuable asset.

Dr Reddy also stressed the need to adequately remunerate them for their competencies. In his paper, he delineated a pantheon of healthcare providers wherein even self care and family care found a pride of place along with allopathic, dental, nurses, midwives, Community Health Workers CHWs, Community Health Volunteers (CHVs), other health professionals, physician assistants and Ayush.

Dr Reddy strongly argued in favour of these subalterns in the health hierarchy of India and made a case for their recognition, respect and adequate remuneration. Dr V K Paul, member Niti Aayog, heading Health and Nutrition Verticals, reinforced Dr Reddy’s stance regarding task shifting by what he said. In his brief intervention in the talk, Dr Paul said, ‘Non Doctors have a huge role and harnessing them effectively to achieve the goal of Universal Health Coverage is the need of the hour.’

Niti Ayog is currently grappling with stiff opposition of IMA, the largest doctors’ body in the country over Bridge Course. The Bridge Course mooted by Niti Aayog is an aspect of task shifting in primary healthcare. Dr Paul, also Chairman of Board of Governors instituted in place of MCI, has played a pivotal role in formulating Ayushman Bharat Initiative.

Giving examples of non doctors used in other countries like in America and Australia and outcomes, Dr Reddy said in no uncertain terms, ‘re-assignment of roles and responsibilities previously restricted to doctors, to non-doctors who have the requisite skill sets, is a rational choice that optimizes all available resources in the health system.’ Task shifting is the process whereby specific tasks are moved, where appropriate, to health workers with shorter qualifications and shorter trainings.

Dr Reddy sampled this. A number of studies (USA, UK, South Africa, and India) have shown that nurses can effectively treat hypertension. In fact BP control was better with nurse managed care than with usual care. ‘Compared with conventional care, a nurse-led hypertension clinic is a more effective intervention for patients with Type 2 diabetes and uncontrolled hypertension.’ – Denver EA et al, 2003. “In nurse led clinic there is greater potential to achieve blood pressure management” – Corrington MJ et al, 2016.

Dr Reddy gave the unique example of a programme of home based maternal, newborn and childcare trial in Gadchiroli (notorious for naxalism in Maharashtra). 39 intervention villages and 47 control villages in Gadchiroli district were selected. One woman from each intervention village selected as ‘Arogya Doot’. Arogya Doots were trained in essential newborn care to provide the following interventions: Health Education of mothers and their care seekers for behaviour change and inducing care seeking; attending home delivery: with traditional birth attendants; care of the baby at birth including management of birth asphyxia; home visits to monitor the health of the mother and newborn; provide special additional care to high-risk babies; management of newborn sickness. • Impact: NMR in intervention area reduced to 25 from 62 in 3 years (62% reduction) while in control areas, it remained at 60 per 1000 live births. And see what Dr Meharban Singh of AIIMS had to say. Dr Singh says, ‘These ordinary looking women of Gadchiroli – these village health workers – know more about neo-natal care than the medical graduates of the All India Institute of Medical Science.” Dr. Meharban Singh.

Quoting data from World Health Organization (WHO), Dr Reddy expressed his concern over the critical shortage of healthcare providers in India. Dr Reddy said, ‘India’s health sector employs 50 lakh workers but skilled health professional density is lower than most of other countries including even Sri Lanka. Skilled health professional density per 10,000 population in India is 20.7 which hardly touches WHO threshold of 22.8 per 10, 000 population.’  Dr Reddy stressed the need to design courses for non physician health care providers and bring about regulatory reforms to undo bottlenecks in innovations.

To refurbish his point of task shifting, Dr Reddy gave examples of developed countries which have adopted Nurse Practitioners as important cog in delivery of healthcare. In United States (US) NPs under state regulations provide many services including diagnosing and treating acute and chronic healthcare problems, performing pre-natal, well-child, well-woman and adult care check-ups, diagnosing and managing minor trauma including suturing and splinting, prescribing medications, and teaching health promotion and disease prevention to patients. In Australia, The Nurses Amendment (Nurse Practitioners) Act (2008) provides for nurse practitioners to be given limited prescribing privileges.

Dr Reddy recommends potential role of the nurses namely enhanced critical role, research coordination & leadership, public health management and training of medical students to be recognized and realized.

National Health Policy 2017 has envisaged Midlevel Care Providers. The National Health Policy proposes – “For expansion of primary care from selective care to comprehensive care, complementary human resource strategy is the development of a cadre of mid-level care providers. This can be done through appropriate courses like a B.Sc. in community health and/or through competency-based bridge courses and short courses. These bridge courses could admit graduates from different clinical and paramedical backgrounds like AYUSH doctors, B.Sc. Nurses, Pharmacists, GNMs, etc and equip them with skills to provide services at the sub-centre and other peripheral levels.”

According to him, even self care is very effective in management of diabetes and hypertension. The efficacy of self care is enhanced by assistance from nurses, CHWs and /or technology. Dr Reddy underlines challenges, opportunities and way forward.

CHALLENGES AND OPPORTUNITIES • Multiple Categories Which Are Poorly Defined And Inadequately Regulated • Resistance To Task Shifting From MCI/IMA • Central Controls on Health Professional Education (direct or via funding channels) Limit Flexibility Of States in Responding To Needs • Demographic Window Of Opportunity For Large Scale Employment Of Youth And Women • Technology Can Enable Efficient And Safe Task Shifting

Way Forward• Design Categories, Cadres and Courses For Different Categories of Non-Physician Care Providers • Health System Needs Must Drive This Process • Competencies (And Not Qualifications) Must Be Valued • Accreditation Based On Competency Based Skilling • Reform Regulatory Structures • To Provide Freedom And Flexibility For Innovation – Remove Regulatory Cobwebs That Favour States Quo.  Team Work and technology to be promoted.

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