By Dr. Arun Jithendra and Nachiket Mor 1
Given the critical role that providers play in healthcare, human resources remains one of the most important challenges in healthcare in both developed and developing countries. And, this problem is made more acute by a particular feature of the healthcare industry that is not shared by other service sectors such as financial access and basic education. This is the fact that while in the case of education and financial access for example, the institutions providing the service need to be licensed, in the case of healthcare, with very good intentions, the licensing requirements devolves onto the individual seeking to provide the service. Almost as a direct consequence of this the investment required to become a licensed provider balloons and so does the need to find lucrative opportunities to earn a reasonable return on that investment. It is not surprising therefore that country after country sees the availability of qualified manpower as the most important stumbling block on offering high quality healthcare to their populations at prices that are affordable. Even on the cost front, the advent of generics and the entry of low-cost manufacturing bases such as India have made many essential drugs very affordable leaving the availability of qualified manpower as perhaps the single most important barrier to providing access to good healthcare.
As a very large developing country in which a states such as Uttar Pradesh with a population exceeding 190 million, independently qualifies to be the sixth largest country in the world, has all of the problems of human resources that other developing countries face but multiplied manifold on account its sheer size and remoteness of many of its parts. Over a decade and a half ago to meet the demand for engineers by its rapidly growing Information Technology sector, India responded aggressively by rapidly expanding the supply of Engineering Colleges and letting market forces decide the issues of quality since its own internal regulatory machinery was not equal to the task and the need was urgent. The number of Engineers Colleges in the private sector tripled from about 550 at the end of March, 1998 to 1500 by the end of March, 2006. The number of engineering students entering these colleges during the same period quadrupled from 125,000 annually in 1998 to over 500,000 in 20062.
However, despite facing a similar level of urgency a similar growth in supply of medical students and medical colleges has not happened. There are a number of reasons that are given for this including the need for much higher levels of investment for medical colleges and the fact that, unlike Information Technology, healthcare after all deals with human life and therefore ex-ante attention to quality has to be perforce much higher. However, perhaps the most important reason for the current state of affairs has been the fact that it is very difficult to get permission to open a new Medical School potentially because the existing community of physicians see a rapid increase in supply as a threat and the reality is that they have good reasons to think so. Something very similar happened in the discipline of Engineering. Prior to 1995 it was considered a very attractive career but post the massive expansion of supply while some disciplines such as Computer Science retained their earlier attractiveness, for the most part the compensation an average engineer could command collapsed. The only reason we draw attention to this detail here is to point out how difficult a challenge it would be to attempt to expand the supply of traditionally trained physicians or to permit new categories of physicians such as Nurse Practitioners to emerge, as has happened in the United States.
Confronted with this reality, acknowledging the futility of attempting to make drastic changes in the supply of traditionally qualified physicians, and needing to find low cost solutions, government, non-profit, and for-profit healthcare providers have gone to the other extreme and have launched a number of programmes in which locally hired, often illiterate women, were offered training programmes of variable quality and converted into Health Workers. The largest such programme in the World is the Accredited Social Health Activist or ASHA programme. ASHA when read as a word instead of as an acronym also means hope or expectation in Hindi thus doing double duty of conveying the original spirit of the programme. As often happens in such programmes the original purity of the design has long been lost and the ASHA now is simultaneously a health activist representing the community, an agent of the government’s conditional cash transfer programme, and most controversially, a dispenser of prescription drugs such as Metrogyl. This last function clearly has a weak regulatory foundation but to the best of our knowledge has never been legally challenged perhaps because the existing community of physicians did not see the ASHA as representing a real threat.
The precursor of the ASHA programme was the famous Mitanin or Friend programme launched in the state of Chattisgarh under the visionary leadership of Dr. T. Sundararaman and was able to show a very large impact even with the Mitanin playing principally the role of an activist3 and not a healthcare provider in her own right, and maintaining her independence from the public health system so that her role as an activist was not compromised. However, in its expanded version, the ASHA programme has effectively been implemented in manner such that the worker in addition is now expected to play the role of a primary care provider as well as refer patients to secondary facilities, roles well beyond her technical capacity to perform with any degree of effectiveness. However, at a smaller scale there have been a number of very interesting interventions with some fairly complex and technical tasks being performed by community health workers. The most famous of this is the work by Dr. Abhay Bang and Dr. Rani Bang in Gadhchiroli district of Maharashtra4 in which they demonstrated that home based neonatal care can be delivered very effectively by well-trained community health workers. It is conceivable that a potential direction for the delivery of healthcare in India could be the growth of such highly trained narrow-skilled community health workers across multiple specialities. However, the legal challenge faced by other community workers persists here as well, aside from the challenges of providing such training at scale and finding the resources to pay all of them a reasonable wage.
Registered Auxiliary Nurse and Midwife (RANM) and the Registered Nurse and Registered Midwife (RNRM)5 programmes do exist in India and offer a potentially strong solution to the challenges of human resources for healthcare, particularly if they are able to practice as Nurse Practitioners as they are in the United States. There are, however, three significant challenges that need to be overcome before this can happen:
- The training that the nurses at both levels undergo is principally as bed-side and emergency room nurses. There are currently no programmes that train nurses to act as practitioners and would perhaps need to be developed from scratch.
- There is severe shortage of trained nurses even for traditional tasks and the supply of nursing schools has expanded very slowly potentially for reasons very similar to those for Doctors.
- Neither the Nursing Council nor the Medical Council are interested in allowing nurses to practice independently and prescribe medicines except for what is specifically required for their role as a midwife.
The IKP Centre for Technologies in Public Health (ICTPH) is a non-profit action-research centre which, among other things, is engaged in developing durable solutions to this challenge of human resources for health in India. After many false starts and legal challenges, they now have a set of ideas that seem to address all of the concerns that have been raised earlier, as well as fit into a full health systems design that they have developed for offering high quality health care in India. Their overall solution involved taking several steps:
- With the help of a top Indian law firm6 ICTPH first researched the legal options available to them taking the current positions of the Nursing Council and the Medical Council as being immutable. They were able to obtain a land mark judgement from the Supreme Court of India which permits the practitioners of specific systems of Indian medicine to also prescribe modern allopathic medicines as well as offer dentistry services in their role as General Practitioners. These systems are Ayurveda, Unani, and Siddha but the Supreme Court specifically excluded Yoga, Naturopathy, and Homeopathy.
- ICTPH then researched the availability, costs, and the willingness of graduates with these backgrounds to serve in remote rural areas. On these fronts ICTPH was able to conclude that a number of such graduates were available and were willing to serve in remote locations at relatively modest compensation numbers.
- On the training front ICTPH discovered that the institutions that train these physicians offer a 5.5 year post-high school programme with a one year internship included. In these 5.5 years they develop a strong understanding of the human anatomy and many other aspects of medicine but significant gaps also remain on many other dimensions. ICTPH then developed its own internal training and certification programme for these physicians, which is a mix of classroom and practical training at any one of the clinics of their local health partner7. It is our understanding that within Cuba such models of training and certifying physicians have gained a lot of traction.
- In the ICTPH training programme these physicians are not only trained to treat patients for common ailments but also multi-skilled to offer dental services, eye care including dispensing glasses, and women’s health including screening for cervical cancer. Very soon ICTPH expects to launch its mental health programme as well as a broader cancer detection and treatment, and tobacco cessation programme.
- All physicians are required to strictly adhere to the internally developed detailed treatment protocols and to enter data for each patient into the internally developed Health Management Information System (HMIS) on a real-time basis. This data is then reviewed carefully by central audit team staffed by experienced nurses and allopaths to confirm that the existing protocols were indeed followed to the letter, to inform the development of new protocols, and to continuously assess the quality of training provided to the physicians.
While research on this is still ongoing, it is our belief that the approach adopted by ICTPH has the potential to offer a durable solution to the challenges of human resources in healthcare for India. The combination of a competent human resource base, intensive training, and a strong control environment, in our view is essential if high quality health care is to be delivered to the larger population. At the secondary and tertiary levels it is our belief also that India has the requisite core competency and that these levels of healthcare would necessarily need to be staffed by physicians and nurses trained in the allopathic tradition. In our view the existing human resource base in the country, with some augmentation in the capacity of both schools of medicine as well as nursing schools would be able to take care of these issues.