|Year : 2020 | Volume
| Issue : 2 | Page : 86-90
Should the AYUSH doctors be underutilized at subhealth centers under Ayushman Bharat while they prove effective at higher facilities under National Health Mission?
Independent Public Health Researcher, Bhubaneswar, Odisha, India
|Date of Submission||20-Jan-2020|
|Date of Acceptance||19-Feb-2020|
|Date of Web Publication||23-Jun-2020|
Dr. Janmejaya Samal
C/O - Mr. Bijaya Ketan Samal, At - Pansapalli, PO - Bangarada, Via - Gangapur, Ganjam - 761 123, Odisha
Source of Support: None, Conflict of Interest: None
AYUSH systems of medicine are the six different indigenous systems of medicine prevalent and practiced in India. Postindependence, these individualized and healer-based systems got government patronization and legal support and converted into medical systems and evolved with time to the present form. From being the department of Indian Systems of Medicine in March 1995 to the Department of AYUSH in 2003 and most recently the ministry of AYUSH in 2014, these systems of medicine have evolved continuously with the growing need of time. With the initiation of National Rural Health Mission in 2005 under the scheme of mainstreaming of AYUSH and revitalization of local health traditions, these systems were promoted at each level and the practitioners came out of their silo and became part of the mainstream health-care delivery system serving both rural and semi-urban communities in the country. However, with the recent AYUSHMAN BHARAT program, these practitioners, especially the Bachelor of Ayurvedic Medicine and Surgery graduates, were offered to serve at the subcenter level as the Mid-Level Health Provider which in a way demotes the cadre. This opinion discusses about this dichotomy situation with AYUSH workforce and government's “easy and soft target” attitude in utilizing AYUSH workforce.
Keywords: AYUSH, health workforce, local health traditions, Mid-Level Health Provider, National Health Mission
|How to cite this article:|
Samal J. Should the AYUSH doctors be underutilized at subhealth centers under Ayushman Bharat while they prove effective at higher facilities under National Health Mission?. Indian J Health Sci Biomed Res 2020;13:86-90
|How to cite this URL:|
Samal J. Should the AYUSH doctors be underutilized at subhealth centers under Ayushman Bharat while they prove effective at higher facilities under National Health Mission?. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2021 Oct 25];13:86-90. Available from: https://www.ijournalhs.org/text.asp?2020/13/2/86/287418
| Background and Present Status of AYUSH Systems in India|| |
AYUSH refers to six different systems of indigenous medical systems prevalent and practiced in India. AYUSH stands for Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy. These systems of medicine are governed by the Department of Indian System of Medicine (ISM) created in March 1995 which got renamed to the Department of AYUSH in November 2003 and provides augmented attention to these systems of medicine.,, During 2014, a separate Ministry of AYUSH was initiated by the union Government of India headed by a minister of state with independent charge. In addition, in 2014, a National AYUSH Mission was also launched along with the celebration of International Yoga Day on June 21 every year from 2015 onward to promote Yoga for holistic health and well-being. As described by the World Health Organization (WHO), of the 7 building blocks of the health system, human resources (HRs) for health play a pivotal role in any health system and AYUSH HRs contribute meaningfully in strengthening the health system in India. Currently, as on January 01, 2018, for each million people, 590.9 AYUSH doctors are serving in the country and the annual growth rate of this workforce from 1980 to 2018 is 2.0%. The acronym National Rural Health Mission (NRHM) and National Health Mission (NHM) has been used interchangeably in this article.
[Table 1] shows the status of AYUSH HR in the country as on January 01, 2018.
|Table 1: Status of AYUSH human resource and population served as on January 01, 2018|
Click here to view
| Mainstreaming of AYUSH System under the National Health Mission and Its Effectiveness|| |
The idea of mainstreaming of AYUSH was conceived during the 9th 5-year plan and subsequently it got ground-level implementation in the year 2005. Through this AYUSH, workforces were mainstreamed and the services were colocated at different levels of health facilities mainly at the level of primary health center (PHC) and community health center (CHC) and in some states both in subdistrict hospital and district hospital (DH) level as well. Under the mainstreaming of AYUSH, both physical integration and functional integration of AYUSH systems have been strengthened. The integration of this system is done through the colocation of AYUSH doctors, supporting staff and creation of infrastructure as per the local needs. AYUSH doctors appointed under NHM facilitate the management, effective monitoring, and implementation of various interventions under the NRHM.
At present, as of June 30, 2018, 498 DHs, 2776 CHC's, and 7623 PHCs were colocated with AYUSH facilities. About 63.9%, 49.4%, and 29.7% of the DHs, CHCs, and PHCs were colocated with AYUSH facilities, respectively. Similarly, around 1.82 million, 0.33 million, and 0.12 million rural population were being served by the facilities colocated with AYUSH services in DH, CHC, and PHCs in the country, respectively by June 2018. In addition, by June 2018, 11840 AYUSH doctors and 3716 AYUSH paramedical staff were found to be working in the country.
It is clear from the above paragraph that the government has created a system where AYUSH doctors were taken out of their silo and were made a part of the mainstream health-care delivery system. They were made to serve at all the hierarchies/levels where most of their allopathic counterparts work. Moreover, studies and reports from time to time also suggest the effectiveness of such integration in the county.,, Apart from the doctors and paramedics, the government has also recognized therapeutics and many interventions as effective against different ailments. One such example is Punarnavadi Mandura, an anemia correcting agent, that has been a part of ASHA drug kit since long and has been in use for the management of anemia among pregnant mothers and adolescent girls in the community., Other interventions such as Ksharasutra (medicated thread) therapy and Panchakarma (five specialized therapeutic modes suggested in Ayurveda) have been used under NHM and found effective for many different ailments.
The AYUSH doctors have been instrumental in effectively handling higher patient load and managing primary care services at all levels of health systems. The terms of reference of these AYUSH doctors suggest that they should provide services in conducting minor surgery, abscess surgery, conducting normal delivery, and insertion of intrauterine contraceptive devices., One of the recent studies conducted on the knowledge and skills of AYUSH (Ayurveda and Homoeopathy) doctors among two districts each from three states of Maharashtra, Rajasthan, and Odisha elicited that 77.1% of these doctors scored 70% or more on items related to essential and emergency obstetrics care. The study observed state-wise variations in the level of knowledge and skills and it might be due to the exposure of such doctors to relevant knowledge and skillsets and state's support for the same. A similar study in Udaipur area of Rajasthan revealed that 86.5% (n = 67) of the AYUSH doctors trained on skilled birth attendant and 41.8% and 40.3% of the doctors have good and average knowledge on skilled birth attendance, respectively. Knowledge and skills regarding partograph use were also found to be high among the doctors in the states of Rajasthan and Maharashtra and were 72.1% and 82%, respectively, however the same was poor among the doctors of Odisha which needs proper evaluation and the doctors should be made to do more practice for the same. A study among 263 patients attending Siddha clinics, colocated with public health facilities, in one of the districts of Tamil Nadu revealed that 99.2%, 94.3%, and 99.6% of the respondents were satisfied with consultation time, doctors' behavior, and counseling on diet and medication, respectively. In another study in Puducherry among selected colocated PHCs with Ayurveda, Homoeopathy, and Siddha doctors, 71.23% (n = 584) of the respondents were satisfied with the services provided by these doctors.
From this, it is clearly evident that AYUSH doctors posted under NHM providing services under colocated public health facilities such as DH, CHC, and PHC are very much helpful in maintaining a healthy workforce equality in rural communities and efficient in rendering a wide range of services needed at each of these levels.
| Promotion of AYUSH in National Health Policy 2017|| |
Historically, the Department of ISM that was formed in 1995 got renamed as the Department of AYUSH in 2003 post-National Health Policy (NHP) 2002. Since then, many developments have happened in the department with the latest culmination as the ministry of AYUSH in 2014 is headed by a minister with independent charge. In continuation with the last NHP 2002, the current NHP 2017 strongly advocates the integration of AYUSH systems of medicine within the existing pluralistic medical care in India. It reiterates the integration of AYUSH systems in the existing NHM, research, and education. Precisely speaking, the NHP 2017 boldly expresses the integration of the AYUSH system with the mainstream health-care system since independence. The NHP 2017 broadly depicts the scope of AYUSH system in mainstream health-care delivery in the country. The policy document acknowledges the state of medical pluralism in the country and emphasizes the amplified role of AYUSH system within this. It underlines the strategies to meet the national health goals with the help of protocol-driven integrative practices. Furthermore, it emphasizes the significance of scientific evidence for safety and efficacy of AYUSH medicines and practices and indicates the need of capacity building, education, and training at the national and international levels., It is clear from this that the AYUSH system occupies a significant position in the integrated health-care delivery system of the country, thereby positioning its workforces in such a critical position.
| AYUSH Doctors as Mid-Level Health Providers under AYUSHMAN Bharat-Health and Wellness Centers and the Resultant Underutilization|| |
The Government of India launched the Ayushman Bharat program in 2018 to provide comprehensive primary care services to the people. It has got two components that directly and indirectly help in providing the preventive and curative health-care services to the people of India. The first component is the National Health Protection Scheme (NHPS) and the second component focuses on the upgradation of the existing subhealth centers (SHCs) into health and wellness center (HWC) that would provide the comprehensive primary health-care services taking a life span approach and begins with care of pregnancy and ends with geriatric care services. 150,000 of such HWCs are planned to be established in the country. The first health and wellness center was established in Jangla, Bijapur, Chhattisgarh, on April 14, 2018, and was inaugurated by the Prime Minister of India which depicts the importance and seriousness of the program.
The HWCs are supposed to provide preventive, promotive, rehabilitative, and curative care for an expanded range of services that include reproductive and child health services, communicable diseases, noncommunicable diseases, palliative care and geriatrics care, oral health, ENT care, and basic level of emergency care. The services in HWCs are being provided through a Mid-Level Health Care Provider (MLHP)/Community Health Officer (CHO) placed at an HWC. Before landing up in an HWC, they should undergo a certificate course in community health through IGNOU or a public university.
As per the WHO, a MLHP is a health worker trained at a higher education institution for at least 2–3 years and is authorized to work independently to diagnose, manage and treat illnesses, diseases, and impairments, and engage in preventive and promotive health activities. However, in the context of India and HWCs, the MLHPs are the CHOs qualified either as BSc. (Community Health) or a nurse (both GNM/BSc.N) or an Ayurveda graduate (Bachelor of Ayurvedic Medicine and Surgery [BAMS]) trained and certified through IGNOU. This training period is currently for 6 months under IGNOU.
Most of the state governments have taken initiatives to enroll and place these MLHPs in HWCs in their respective states. In one of the recent news, it was seen that 5700 graduates from Ayurveda, Unani including nursing were recruited to join the bridge course and is being practiced in most of the states. The main shortcoming is that the AYUSH graduates, especially the BAMS graduates, have shown effectiveness in working at higher centers; thus, it appears to be an underutilization step by the Government of India. Some authorities claim this as a downgrading approach for the AYUSH fraternity in India. In addition, the NHPS does not acknowledge AYUSH doctors or drugs as they do not qualify empanelment.
Hence, it would be better to keep the AYUSH doctors posted at all levels of health care, mostly at the higher level, PHC to DH, and allow them to work as effectively and efficiently as they are currently working at these centers. For the subcenter level, HWCs nursing cadres should be preferred; however, for PHC level HWCs, AYUSH graduates can be considered.
| Conclusion and Recommendation|| |
Since the inception of NHM when AYUSH doctors were colocated at DH, CHC, and PHC levels, they have been effectively and efficiently rendering public health services. They have also been successful in providing services for emergency and essential obstetric care, primary health care, and other basic medical and surgical emergencies. With the acute shortage of qualified doctors in rural India, limiting the services of AYUSH doctors to a limited number of SHC-HWCs under AYUSHMAN Bharat program is a kind of underutilization of this workforce as they are effective at higher level serving more populace under NHM. Instead of utilizing AYUSH doctors for this, the nursing personnel should effectively be used for the MLHP position. In Odisha, a different model of utilizing AYUSH doctors as MLHP is found, in which the AYUSH doctors as MLHPs sit at the PHCs (PHC-new) and cater services to a bunch 4–5 SHCs guiding the team of SHC staffs. This model appears more effective as they would serve both purposes, as MLHPs and PHC doctors. Such models would be more viable options and should be tried in other states as well if not tried yet.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Samal J. A brief assessment of Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy health system based on Five-year Plans of India. Int J Green Pharmacy 2016;10:S91-5.
Department of Indian System of Medicine and Homoepathy. National Policy on ISM and H. New Delhi: Ministry of Health and Family Welfare, Government of India; 2002.
AYUSH in India. Planning and Evaluation Cell, Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH). Government of India; 2014.
National Health System Resource Center-National Rural Health Mission, Mainstreaming of AYUSH and Revitalization of Local Health Traditions Under NRHM, An Appraisal of the Annual State Program Implementation Plans 2007-2010 and Mapping of Technical Assistance Needs. New Delhi: Ministry of Health and Family Welfare, Government of India; 2008.
Mishra A, Nambiar DH. The making of 'local health traditions' in India. Econ Polit Wkly 2018;53:41.
Samal J, Dehury RK. Can the AYUSH system be instrumental in achieving universal health coverage in India? Indian J Med Ethics 2018;3:61-5.
Samal J. Role of AYUSH workforce, therapeutics, and principles in health care delivery with special reference to National Rural Health Mission. Ayu 2015;36:5-8.
] [Full text]
Samal J. Role of AYUSH doctors in filling the gap of health workforce inequality in rural India with special reference to National Rural Health Mission: A situational analysis. Int J Adv Ayurveda Yoga Unani Siddha Homeopathy 2013;2:83.
Samal J, Dehury RK. A review of literature on Punarnavadi Mandura: An ayurvedic herbo-mineral preparation. Pharmacogn J 2016;8:180-4.
Savrikar SS. Critical comments on “Allopathic, AYUSH and informal medical practitioners in rural India: A prescription for change”. J Ayurveda Integr Med 2019;10:72-3.
Samal J. What makes the Ayurveda doctors suitable public health workforce? Int J Med Sci Public Health 2013;2:785-9.
Chandhiok N, Singh S, Chaudhury N, Shrotri A. Knowledge and skills of ayurvedic and homeopathic practitioners to provide skilled birth attendance in India: An observational study. Indian J Community Med 2018;43:175-9.
] [Full text]
Kumar A, Keerti KK, Sharma CP, Sharma S, Garg K, Jain R. Assessment of knowledge and performance of AYUSH doctors posted in collocation under National Rural Health Mission in Udaipur Division Rajasthan. Natl J Community Med 2013;4:608-12.
Chandhiok N, Shrotri A, Joglekar NS, Chaudhury N, Choudhury P, Singh S. Feasibility of using partograph by practitioners of Indian system of medicine (AYUSH): An exploratory observation. Midwifery 2015;31:702-7.
Venkatachalam D, Selvaraj K, Ramaswamy G, Veerakumar A, Chinnakali P, Saya GK. Are patients satisfied with accessibility and services provided at siddha hospitals? Findings of patient satisfaction survey from a district of South India. Int J Community Med Public Health 2018;5:2596-9.
Boovaragasamy C, Narayanan S. Patients' satisfaction regarding facilities and services provided at AYUSH clinics of primary health centres in rural Puducherry. Int J Community Med Public Health 2019;6:2498-504.
Samal J. Situational analysis and future directions of AYUSH: An assessment through 5-year plans of India. J Intercult Ethnopharmacol 2015;4:348-54.
Government of India. National Health Policy 2017. Ministry of Health and Family Welfare. Nirman Bhawan, New Delhi: Government of India; 2017. p. 1-32.
Shankar D, Patwardhan B. AYUSH for New India: Vision and strategy. J Ayurveda Integr Med 2017;8:137-9.
National Health Authority. Pradhan Mantri Jan Arogya Yojana. National Health Authority; 2019. Available from: https://www.pmjay.gov.in/
. [Last assessed on 2019 Aug 15].
Model Tender Document for Selection of Implementation Support Agency for Providing Support Services for the Implementation of Ayushman Bharat – National Health Protection Mission. Vol. 2. AB-NHPM, Schedule of Requirements. Specifications and Allied Technical Details; 2018.