A National Medical Commission (NMC) proposal in the National Medical Commission Bill and the National Health Policy 2017, of allowing Ayush (Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy) practitioners to practise basic and limited allopathy on completion of a bridge course has stirred a hornets’ nest. Faced with strong opposition from allopaths, the Union cabinet in its latest amendments withdrew the proposal and passed on the responsibility to states to utilize this as a strategy for addressing human resources gaps in primary healthcare. Even if politically expedient, the cave-in is faulty.

India faces an acute shortage of allopathic doctors, with the present doctor-patient ratio at an abysmal 1:1,674. The last mile of healthcare delivery in India occurs through sub-centres and primary health centres (PHCs). But 61.2% PHCs have just one doctor, while nearly 7% are functioning without any. More than a third of them do not have a laboratory technician, a fifth of them do without a pharmacist.

In Odisha, 3,119 of the 6,536 posts for doctors are lying vacant. India’s health system clearly has an acute shortage of doctors. The country needs nearly 500,000 doctors to address this shortage. In such a milieu, unqualified medical practitioners often rule the roost. In states such as Uttar Pradesh, Jharkhand and Bihar, a patient faces two-third chances of getting treated by a quack. While the government works on increasing the number of MBBS and matching postgraduate seats, we also need to ensure that the current healthcare needs of our population are fulfilled.

In the grand “Ayushman Bharat" scheme of things, upgraded subcentres and PHCs, to be called health and wellness centres, will serve as the fulcrum for delivering primary healthcare. It’s unclear, however, how the staffing needs of these centres would be met in a uniform manner nationally. Given the paucity of MBBS doctors in rural areas, it makes sense to leverage the ready availability of a large population of willing Ayush practitioners. With the availability of appropriate bridge courses, sound regulatory and licensing mechanisms, Ayush graduates should be given a chance to help serve India’s primary healthcare needs.

A factor that contributed to the outrage against the “bridge course" could have been its suggested duration of a measly six months. In courses like Ayurveda, nursing, physiotherapy or pharmacy, the curriculum has several strands similar to that of a MBBS course; additional training in pharmacology and basics of medicine with clinical clerkships could provide them an orientation to be able to practise “limited" allopathy. The bridge course can be delivered through premier Ayush colleges, and selected district hospitals.

There are examples of such programmes in the West. A physician assistant (PA) in the US comes out of such a programme, often taken up by paramedics and nurses, who can after a two-year course and passing a certifying exam become assistants to doctors. With bachelor’s and master’s degrees available, flexibility of online and on-the-job learning, the PA course is a design from which the bridge course can draw inspiration. As of 2017, the 115,500 US PAs saw 8.1 million patient visits.

The UK model of physician associate, in a two-year training period, focuses on general adult medicine and general practice. In New Zealand, the Centre for Rural Health Development identifies PAs as “postgraduate healthcare professionals trained in a clinical role that complements both nursing and medicine, and working under the supervision of a senior doctor", who form an important cog in the wheel of rural healthcare.

As of 2013 in Bangladesh, three-year training qualifies a sub-assistant community medical officer (SACMO) to practice. Incidentally, 89% of healthcare delivery in rural areas is being taken care primarily by SACMOs. Assistant doctors in China, clinical associates in South Africa, and assistant medical officers in Malaysia are all based on similar models.

The allopathic doctors’ community, led by the Indian Medical Association (IMA), should not see this move as legitimization of “quackery". A bridge course can help bring Ayush candidates to speed on allopathic prescribing for a required set of conditions—this is not to make them half-way quacks (as IMA would like us to believe) but to actually practise base-level primary healthcare provisioning. Their training and curriculum can be ring-fenced, and regulatory restrictions brought in to ensure they only practise within the allowed ambit. Moreover, there are positive externalities at multiple levels in training the Ayush provider to serve a primary healthcare domain need.

Such a provider can help initiate a focus on disease prevention, a dire need considering India’s continuing burden of both communicable and (rising) non-communicable diseases. For a specific set of conditions defined by the government, the Ayush provider can initiate treatment, manage follow-up, and initiate referral when needed. This would ensure that standard treatment protocols are followed. It can help address irrational medical practice, and existing rampant abuse of drugs such as antibiotics.

Putting the ball in the court of state governments to address primary health in rural areas through local bridge courses is a defective approach. While implementation can be at the state level, the design of the course, the legal framework, and a standardized plan should be the Centre’s responsibility.

During World War II, when the requirement of physicians arose tremendously, fast-track training was successfully adopted in the US. This now serves as the educational model for PAs. The proposed redesign of India’s health system, a much touted reform by the current government, will falter in the absence of enabling innovations like a bridge course to raise a cadre of mid-level care providers to serve our primary healthcare needs.

Sambit Dash and Anant Bhan are, respectively, a biochemistry teacher at the Melaka Manipal Medical College, MAHE, and a researcher in global health and bioethics and an adjunct professor at Yenepoya (deemed-to-be-university), Mangaluru.

Comments are welcome at theirview@livemint.com

Close