Setting the tone – Understanding the significance of the unheralded MLHP for India
According to a needs-based assessment conducted by the WHO in 2013, there was a global shortage of 17.4 million healthcare workers- approximately 2.6 million doctors, 9 million nurses and midwives and other cadres.1 The report pointed that the largest shortage of medical workers existed in Southeast Asian nations (6.9 million) and in Africa (4.2 million). As such, the significance of MLHPs has been broadly examined by different organizations in the world and a majority of these studies substantiate that MLHPs can be a promising resource in the path towards achieving Universal Health Coverage- an important aspect of health goals laid out in the Sustainable Development Goals by the United Nations. However, there is no global uniformity in defining MLHPs and thus, policies and acceptance around this crucial health cadre seem to be varied and less comparable across countries. In simple terms, MLHPs or CHOs are healthcare providers, who are not certified doctors or physicians, and who are licenced to administer treatment in hospitals or primary health centers. Across the globe, they are known by many nomenclatures including - nurses, nurse auxiliaries, mid-level providers (MLPs), substitute health workers, non-physician clinicians, midwives and many more. Generally, a MLHP is defined by the WHO as a health provider - who is trained, authorized and regulated to work autonomously, who receives pre-service training at a higher education institution for at least 2-3 years and whose scope of practice includes (but is not restricted to) being able to diagnose, manage and treat illness, disease and impairments (including perform surgery, where appropriately trained), prescribe medicines as well as engage in preventive and promotive care.2 In India, the National Health Mission defines MLHP as a Community Health Officer (CHO) who has a B.Sc. degree in Community Health or a Nurse (GNM or B.Sc.) or an Ayurveda practitioner, trained and certified through IGNOU/other State Public Health Universities for a set of competencies that enable him/her to deliver public health initiatives and primary healthcare services 3. Thus, CHOs in India are interchangeably referred to as MLHPs and vice-versa.
In the last few decades, the role of MLHPs in India has gathered a lot of attention which has simultaneously sparked off a variety of discussions on their role in enabling improved reach and effectiveness of primary care delivery. Learnings from the healthcare systems of many nations have shown that the integration of MLHPs can be beneficial for communities to receive health deliverables for their respective populations. India has also recognized the importance of this section of health workers and has proposed certain capacity building programs to further refine and utilize this resource appropriately. The primary objective of this paper is to provide nuanced perspectives on the importance of mainstreaming MLHPs in the public healthcare systems (specifically primary healthcare) in India. We also attempt to discuss the context, the nature of integration expected and the existing challenges in absorbing this cadre and potential solutions thereof.
Recognising the Role and Relevance of MLHPs for Primary Care
The relevance and demand for MLHPs has risen ever since countries around the world encountered severe communicable illnesses such as the HIV/AIDS pandemic, particularly in African and Asian nations, that pushed their health systems into the brink of collapse. Traditionally, MLHPs have been particularly employed to provide services in the spheres of maternal and child health as well as communicable illnesses in many parts of the globe.4 A study from Thailand showed the positive contribution of nurses and midwives in post-partum tubal ligation wherein they ended up delivering satisfactory results.5 This is a clear signal that if trained properly, MLHPs can provide safe and worthy healthcare interventions. Another study explored the level of comfort that patients experienced while being attended by nurses and midwives as opposed to doctors and the results were positive again.6 In a study intended to comprehend the level of maternal satisfaction while carrying out medical examination of their new-born babies by midwives and junior paediatricians, it was reported that mothers were more satisfied when the medical examination was carried out by midwives because of their level of involvement, careful scrutiny and the likelihood of continuation of care.7 A bulk of evidence on the outcomes of care delivery by MLHPs come from African nations where mid-level providers have been integrated early on. Interestingly, Africa also has had a long-established practice of employing non-physician clinicians to deal with high incidences of illnesses necessitated by an acute shortage of medical personnel. An added advantage has been the reduced cost of managing and employing them, relaxed regulations in terms of their educational qualifications and their readiness to join the health workforce. Even though the roles of the MLHPs vary across countries, they are majorly involved in carrying out diagnosis, offering treatment as well as managing complicated procedures such as Caesarean sections, ophthalmology and less relatively in administering anaesthesia.8 Many Sub-Saharan countries have gradually made a decisive shift to integrate MLHPs to address their primary healthcare needs and this is something that is increasingly worth emulating by other LMICs.
The context of integrating MLHPs into the public health system in India
The concept of MLHP is not very new as it has existed for over a century in different forms and with diverse nomenclatures across the world. Particularly in low-income nations, MLHPs (then known as auxiliaries) have existed for long and have provided medical care to indigenous populations since professional healthcare in the early colonial days was somewhat available only for the elites.9 Health auxiliaries have been active since the 19th century and have contributed significantly as smallpox vaccinators and contributed to eradicating and managing several diseases including yaws, sleeping sickness, tuberculosis, venereal diseases, leprosy and more recently, malaria.10
According to evidence on Health Workforce Requirements for Universal Health Coverage and Sustainable development Goals (2016) from the WHO, there is a global shortage of about four million medical professionals with quite an absolute shortage in India and Bangladesh, followed by the rest of South Asia.11 According to National Health Workforce Account (NHWA), there are approximately 5.76 million health workers in India (about 1.16 million allopathic doctors, 2.34 million nurses and midwives, 1.20 million pharmacists and 0.27 million dentists). However, the active health workforce in India is far below these statistics. The Periodic Labour Force Survey (2017-2018) of the National Sample Survey Office (NSSO) in India also estimates that the density of active doctors and nurses/midwives to be 6.1 and 10.6 respectively per 10,000 persons.12
As witnessed above, India has a maldistributed workforce in terms of geographic availability, rural-urban disparity, skills and inclusivity. The gap is poorly skewed in rural parts and rural hilly regions in India with much of the health workforce available in the urban regions.13 In an attempt to address this issue, the Government of India launched one of its flagship programs – the National Rural Health Mission (NRHM) in 2005 and what is now known as the National Health Mission (NHM). The aim of this mission has been to work towards the “attainment of universal access to equitable, affordable and quality healthcare services, accountable and responsive to community needs, with effective inter-sectoral convergent action to address the wider social determinants of health”.14 In 2019, the Government of India introduced the National Medical Commission Bill which aimed at redesigning the medical education system in the country to ensure the availability of adequate and high-quality medical workers and improve care delivery by adopting latest medical technology and research and improved inspection and grievance mechanisms in medical institutions. The bill also considered granting a limited license to a number of MLHPs to practice medicine. Under this license, the MLHPs were to be allowed to prescribe specified medications in primary and preventive healthcare contexts. If need be, they could also prescribe medicines under the supervision of a registered practitioner. While initial feedback seems to be positive on this implementation particularly in rural communities; a large longitudinal study is required across the nation to evaluate the outcome of this implementation and explore how communities have benefitted from this new role.
A wide range of studies point towards the importance of MLHPs in primary healthcare setups. Primary healthcare is the most vital pillar for any country, especially for developing countries. It is the first point of contact between a patient and a medical professional and is often situated at the community level. In India, the Sir Joseph Bhore Committee in 1946 proposed to rapidly set up primary healthcare centers to provide preventive, promotive, curative and rehabilitative services, especially for the rural population. The committee aspired to improve access to healthcare and reduce out of pocket expenditure for medical needs. The Report of the Health Survey and Development Committee by the Bhore Committee emphasized on the need to establish Primary Health Centers (PHC) and sub-centers in rural India. It recommended improvising medical infrastructure in rural parts of India and proposed that there should be one PHC per 40,000 population.15 This particular objective of the Bhore committee was later echoed in the Alma-Ata Declaration of 1978 by the WHO which defined primary healthcare as the most important key to attain the goal of “Health for All”. However, primary healthcare still remains an unfulfilled project in many developing countries; with the prevalence of an inverse primary healthcare law - a situation wherein the availability of medical personnel is inversely related to the levels of poverty and requirement. The primary health care sector in India is largely fragmented on various fronts- availability of service providers, their knowledge, state-wise differences, level of their education and so on. There is also sparse data on factors such as cost per patient across states and the number of visits for a particular illness. Moreover, the reluctance of formally trained doctors to serve in rural areas provides a way for many informal providers to deliver healthcare services in these areas.16
A combined outcome of such paucities in primary healthcare in India is the worrisome prevalence of several untrained and informal workers, particularly in the rural parts of India. A study that included 1519 villages across 19 most populated Indian states revealed that the availability of informal workers is the highest at 68%, followed up by AYUSH providers at 24% and a very low presence of trained MBBS professionals (8%). This naturally translates into the public access to providers - with 75% of the sampled villages have access to mainly informal workers. They are often the first point of contact for people in extremely rural pockets of the country who have barely any access to medical professionals or hospitals in their immediate vicinity. Such informal providers are commonly present in most other low and middle-income countries besides India.17 Another study highlighted the predominance of informal health workers in rural India. The reluctance of formally trained doctors to serve in rural areas provides an opportunity for informal providers to deliver healthcare services in these far-flung areas. Reportedly, many villages in the large Indian states of Madhya Pradesh and Rajasthan have informal workers as the only proximate source of healthcare.18 The Health Ministry under its Ayushman Bharat programme has recently started to promote the need to provide relevant training to MLHPs to work in the newly established Health and Wellness centers (HWCs).
The Government of India’s Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) program calls to strengthen Primary Health Centers (PHCs) through the establishment of Health and Wellness Center (HWCs) and Sub-Health Centers (SHCs). The care delivery here is conceived as assigned to MLHPs or CHOs in HWCs and the PHCs (both urban and rural) will be managed by the existing Medical Officers (MOs). In order to be recruited and positioned in an HWC, the MLHPs/CHOs need to undergo a training and obtain certification in Community Health from the Indira Gandhi National Open University (IGNOU, India). Thus, policy frameworks with regard to strengthening primary healthcare have gone through many phases and a long pathway - from the Bhore committee to the National Rural health Mission (2005-2012) to PMJAY. However, Universal Health Coverage (UHC) in India in its truest sense is yet to see phenomenal traction. While there could be various reasons for the lack of a systematic analysis or due to the fact that policies have encouraged increased privatization in a failing public health scenario or due to the lackadaisical recruitment of health workers and nature of operative control over facilities (Goel, 2007)
Moreover, since India is a signatory to the Sustainable Development Goals (SDGs) which affirms that the country aspires to work towards achieving Universal Health Coverage by 2030. With the motive to meet the health goals specified under the various indicators of the SDGs, India aligned its National Health Protection Scheme in 2016 to provide financial access to over 500 million Indian poor to help them achieve secondary and tertiary care. The significance of primary healthcare (as discussed above) gained further focus after the onset of the SDGs. In order to strengthen the realization of the health-related SDGs, member states reaffirmed their commitment through the Declaration of Astana, 2018; that aims to enhance primary healthcare mainly through three major steps- service delivery, multisectoral actions and empowering citizens.19 It is believed that the MLHPs in India can have a robust impact in achieving these health targets, specifically with regards to target 3.1 (reduction in maternal mortality), 3.2 (reducing infant mortality), 3.3 (ending epidemics and communicable diseases) and 3.4 (providing mental health support). Despite recognizing the role of MLHPs in primary healthcare, the Governments of many states have not been able to adequately employ them and fill the vacant positions in order to accelerate access to healthcare. It is believed that in order to achieve the “Health for All” objective of the United Nations Sustainable Development Goals, India will have to double the current density of doctors and pharmacists to enhance maternal care and child delivery by 2030.20
A very interesting WHO assessment that evaluated the contribution of CHOs in the HWCs of Indian states of Assam and Chhattisgarh has highlighted that CHOs have been crucial in delivering care during the most challenging times of Covid-19 pandemic. Moreover, the community reported a higher sense of comfort and reliability on CHOs and indicated that they preferred to visit the HWCs over higher level centers. The study also confirmed that CHOs have a better track record of treating certain medical conditions such as NCDs, maternal and childcare, diabetes and hypertension. However, the findings also highlighted gaps in the management of conditions such as diarrhoea, vulvo-vaginal candidiasis and pre-eclampsia; which are conditions with a relatively lower incidence and thus, lower availability of algorithm-based protocols.21 These findings further reinforce that CHOs can provide better care with continued training and supervision.
Inherent challenges while integrating MLHPs into existing hierarchical health systems
While there has been heightened consensus that integration and collaboration in distribution of health resources would lead to overarching improvements in the healthcare segment; however, there could be potential challenges to the successful integration of cadres such as the MLHPs into hierarchically built and operated health systems. For instance, the lack of conceptual clarity in defining the role of the MLHP, the empirical challenges and the research bias in the available data and so on are crucial impediments.22
Another potential challenge is encountered in the integration of mid-level health providers into mainstream healthcare systems wherein there are signs of initial reluctance from physicians, who felt their area of work was being infringed upon, in delegating responsibilities to MLHPs. Such biases could also hinder the successful integration of MLHPs into the health systems.23
A significant hindrance seems to arise from a skewed understanding of community needs in many developing nations including India. As seen in Guatemala, the biggest challenge in fully integrating CHOs into the primary care is a problematic managerial perception that adheres little to no importance to support community-level needs that prioritises the local issues.24
This managerial bias against community integration is found to be one of the biggest challenges in the successful integration of MLHPs into mainstream healthcare systems and was aptly documented while studying the impact of ICT in augmenting primary care delivery by MLHPs in the South African context. The findings suggest that the introduction of ICT based delivery would be futile if the community needs are not adequately incorporated.25 According to Munshi et al., many of the programs aimed at improving care delivery through CHOs fail in countries such as South Africa because of a lack of consideration of community needs and local factors and these contextual issues would be similar for other LMICs such as India.26 MLHPs and more specifically AYUSH (Ayurveda, Yoga, Unani, Siddha & Homoeopathy) based-providers who inherently represent a stream of medicine that is innately overshadowed by the wider allopathic system may find additional challenges of stream integration. This could be a potential challenge in upscaling and standardizing this cadre.