India will need over 2,50,000 fully staffed primary care teams to ensure universal access to primary care suggesting an overall requirement of 1.25 million personnel
Availability of trained human resources is considered to be one of the most important challenges facing us in India, as we plan ahead for universal access to primary care. Indeed, as we consider the possibility of offering primary care to 1.3 billion people, with one four-to-five-person primary care health-team for every 5,000-person unit, it does seem like a daunting task. With this level of coverage, India will need potentially more than 250,000 fully staffed primary care teams in order to ensure universal access to primary care suggesting an overall requirement of 1.25 million personnel.
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However, against this requirement, there are already about 500,000 pharmacies in India with one or more full-time staff members, 1 million ASHA workers who work on a part-time basis with the government, 1 million Anganwadi workers, 200,000 auxiliary nurse midwives, and a very large number of health workers employed by the 1 million health establishments that are operative in the country.
Besides, about 10 million individuals graduate from Indian colleges each year with an undergraduate degree in various disciplines. These numbers suggest that both within government and outside it, there are more than an adequate number of people to allow us to properly staff all the required primary care facilities. If there is a challenge it is not that of absolute numbers but rather of the distribution of roles and the adequacy of training to perform those roles.
Additionally, as we plan for the human resource requirements for a high-quality primary care system within the country, it is imperative that the planning include some of the core aspects of a good human resources plan, such as the opportunity for career advancement, and mobility between jobs and between regions so that if circumstances change or working conditions are not found to be satisfactory, the health worker can move to search for better prospects.
The possibility that this mobility exists will also ensure that employers are willing to treat their healthcare workers with the respect that they deserve. The other important consideration is that the person must be able to be gainfully employed alongside getting their certifications, and the training must comprise a combination of field and academic instruction and take a “credits-based continuum” approach so that not only do they benefit from the experience on the field but also that when they graduate, they are job-ready from the first day itself.
In terms of the categorisation of these jobs, while myriad taxonomies are possible, most primary care systems draw from healthcare workers who can perform one or more of the following four roles: legally prescribe medicines; partner with the prescriber, but with only partial prescription capabilities; triage patients and work closely with them, but without any prescription capabilities; and work in field settings.
These four could be thought of as independent roles with stand-alone careers but could also permit career-progression pathways starting from a field setting all the way to performing the role of a prescriber.
In addition to training, computerised decision support systems operating on top of good electronic patient health records, in combination with suitable diagnostic devices, can substantially enhance the capabilities of these healthcare workers and can allow them to perform at a very high level and to cover a full range of conditions from infection to chronic diseases.
In fact, the entire training program would need to be designed around such technology platforms so that when they complete their training they emerge as completely adept users of these technologies. This will also allow their training to move away from rote memorisation to actually building the full range of skills required for success in primary care settings.
Thailand has built a large workforce of highly specialised healthcare workers at the prescriber level starting with field workers by creating the opportunity for explicit career pathways from them.
Alaska, on the other hand, has the taken the view that a single individual can be permitted, with suitable training and supervision, to perform all four roles, in their Community Health Aide Program (CHAP), starting with a basic high school diploma. The Alaskan Community Health Aides are nominated by remote rural communities for training and upon completion of the initial round, return to the village for their placement.
Over the next several years this process is repeated and after each level of training, they acquire the ability and the legal capacity to provide higher levels of services.
In India, several such high-quality programs exist as well. SEARCH, a healthcare focussed non-profit headquartered in Gadchiroli, has developed a highly-rated training program which provides a combination of field, triage, and partner level capacities to health workers drawn from the local community.
Karuna Trust, a non-profit headquartered in Bengaluru, has developed a program to train healthcare workers drawn from tribal communities as triage and field-level workers. The Banyan, a mental health focussed non-profit based in Chennai, trains healthcare workers drawn from local communities, as specialised providers of mental healthcare services at the field and triage levels. The PanIIT Alumni Foundation has developed a two-year residential training program in Jharkhand, which offers high school graduates field and triage level capabilities at a very high level of competency.
Each of these programs is highly scalable and with minimal investment can provide field and triage level capabilities and certifications to large numbers of individuals for placement within healthcare facilities around the country. Partner level training would need close collaboration with the Nursing Council so that health workers who have been trained at the triage level can proceed to train to be a partner in a smooth way.
Prescribers can be doctors with an undergraduate qualification but could also be Advance Practice Nurses or Nurse Practitioners who have already been trained as partners.
Additionally, those states that are willing to permit this formally qualified non-MD physicians with formal bachelor’s degree qualifications in the three Indian Systems of Medicine (Ayurveda, Siddha, and Unani) could be retrained to be prescribers and to practice allopathic medicine, following the 1998 Mukhtiar Chand Versus the State of Punjab judgement of the Supreme Court of India.
While India does not yet have such a policy in place, many countries have significantly expanded their primary care offerings by working with pharmacists as providers of healthcare services ranging from vaccinations to comprehensive treatment of primary care.
In Brazil, for example, pharmacists participate comprehensively in the screening and treatment of a wide range of chronic diseases and trained to measure hypertension, draw blood, and use the peak flow metre to assess COPD.
In Indonesia, the Pharmacist Association offers many training programs which train pharmacists on the diagnosis, treatment, and management of non-communicable diseases.
Pharmacists are highly knowledgeable about drugs, have access to a cold chain, and through their physical outlets maintain continuous contact with members of the local community. This makes them highly suited to providing primary care, particularly as it relates to the much-neglected area of non-communicable diseases.
While the availability of suitably trained personnel for comprehensive primary care is indeed currently a challenge for us in India, there are several ways in which the gaps can be filled relatively smoothly to the point that, as has happened in the case of nurses in some states, we in India not only have a sufficient supply for our needs but we become a large supplier of well-trained healthcare personnel for the world. With our strengths, we are well placed to do so.
This article is written by Nachiket Mor, a Visiting Scientist at The Banyan Academy of Leadership in Mental Health and member of the Health Insurance Advisory Committee of IRDAI. The views are personal.
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