The Impact of the IOM

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The dilution of public health services during the post reform period and its implications for the health status of the population generated wide attention among the public health activists in India. The policy shifts towards privatization of health care accompanied by reduction in public investment and introduction of user fees in public health institutions, unregulated growth of private players and increase in cost of treatment, eliminated the majority of the population from the ambit of the health services delivery.

The dilution of public health services during the post reform period and its implications for the health status of the population generated wide attention among the public health activists in India. The policy shifts towards privatization of health care accompanied by reduction in public investment and introduction of user fees in public health institutions, unregulated growth of private players and increase in cost of treatment, eliminated the majority of the population from the ambit of the health services delivery.

Further, the changes in the public policies adopted in the aftermath of selective primary health care focused on target based and ‘tangible’ activities with a narrow perception of ‘health’. In the context of debates around ‘universal health coverage’, the Indian Public Health Movement is actively involved with issues such as access to medicine, regulation of pharmaceutical industry, community participation and responsiveness of care etc.

For the purpose of the present exercise, I selected the issues with human resource development which is one of the major component hindering the availability and quality of care. 1. Health Workforce ‘Shortage’ The human resource shortage is projected as one of the major impediments for delivering quality care in the public health service system. The data shows that there is only 0. 69 doctors for 1000 population in India. Further, there is an estimated shortage of six lakh doctors, ten lakh nurses and two lakh dental surgeons (World Bank 2012).

In this context, it is significant to understand what constitute this ‘shortage’ and how can we address it with the existing resources. Broadly speaking, the term human resource shortage (in health service system) denotes inadequacy at numerical level and at the specific skill-mix of the workforce. It is interesting to look into this ‘shortage’ in relation with the hierarchies existing within the health service system.

These hierarchies can be located at three levels viz., (i) conceptual level where curative dimension getting priority over promotive, preventive and rehabilitative services; (ii) professional level where supremacy of doctors over all other staff; and (iii) preference for Allopathic practices which undermine other systems of medicine such as Ayurveda, Unani, Homeopathy, other indigenous practices etc. 2. Policy Issues There are three major areas required particular attention: (i) Inclusive care: The existing practices are dominated by curative dimension of health care.

This demand specifically trained professionals and establishes a hierarchy of medical doctors over para-medics. A shift in the focus is required at the primary health center level towards the preventive and promotive aspects of health. The rehabilitative component of the health care is totally absent at the PHC level in India. The given context emphasizes the need for a shift from the techno-centric model to people-oriented model in which the social determinants of health are well recognised.

This model expects to bring a change in the hierarchies with community health workers being the vehicles of change at PHC level. The National Rural Health Mission (NRHM) partly envisaged this role through Accredited Social Health Activists (ASHA). The mitanin programme in Chhattisgarh is also an example. With the understanding that not all the ailments/situations require doctors, recognizing and upgrading the skills of para-medics including licensing nurse practitioners is widely in discussion in India.

(i) Directly linked with health manpower development: The demand for professionals and their skill levels are directly linked with the focus of PHC on the dimension of care. As we mentioned above, the curative-centered system demands more skilled (technically) professionals, availability of which is not in congruence with the ground reality in India. This may be due to (i) non-availability of professionals; (ii) non-willingness to work in rural and remote areas; and (iii) lack of adequate funds to support the professionals.

The non-availability of professionals may be due to lack of training facility and/or due to migration to private sector, urban areas or abroad for better options. The policy level discussions in this context put forward measures to (i) regulate migration, circular migration and use of skill of returned migrants; (ii) mandatory rural service for young medical graduates and allotting grace-points for higher studies; (iii) incentives for rural and remote area service for professionals; and (iv) improving the infra-structure at the rural institutions.

(iii) Inclusion of other systems of medicine: The department of AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy) established by the India government is a welcoming step in the direction of recognizing the practices of other systems of medicine and supporting them to address the challenges in public health in India. Further, there are some attempts to provide the services of these systems through public institutions under one umbrella. 3. The Main Players.

•The state need to increase public investment in health (the current figure is 1% of GDP), restructure the health service system with a focus on ‘inclusive’ and ‘universal’ care, reorient the medical/health education with emphasize for rural area care; regulation of training institutions and ensuring quality, empowering the local government institution and increase their role in identifying the need of the particular area and planning. •Bilateral/multilateral agreements on health manpower utilization are gaining significance in the context of migration of skilled workers.

India needs to effectively develop strategies to compensate the brain drain by ensuring return migration or use of their upgraded skills for a particular period. The right to health of the population and right to work (migration for better opportunities) of the professionals need to be balanced on a mutually beneficial manner. •Professional associations: Physicians’ and para-medics’ associations have active role in improving the quality of care as well as the working conditions in public health institutions.

The mobilisation and recognition of professionals in other systems of medicine is also important. •Civil Society Organisation: The achievements in public health in India are largely linked with public action and the state’s responses. So the civil society organisations have an important role in sensitizing the public, monitoring the services and critically evaluating the system. 4. Challenges The hierarchies established between different professions (doctors and para-medics) and that between Allopathy and other systems of medicine is an impediment to the achievement of universalisation of health care.

Critical thinking and radical restructuring of the health service system is required to address these issues. Identifying the healthy practices and transcending the boundaries of different systems of medicine is a major challenge to make use of the expertise in all the available resources. The certification of degrees and license for practicing certain methods in different systems need to be systematized. For instance, the discussion over permitting Ayurveda practitioners to perform surgeries generated opposition from Allopathic practitioners.

Another significant issue is to negotiate with the different professional associations having conflicting interests. In 2010, there was an attempt to introduce a three and a half year degree in rural medicine and surgery designed specifically for rural population. But this was withdrawn due to strong objection from medical associations. The ‘task-shifting’ approaches such as nursing practitioners in specific areas as per need have to be recognised in India. 5. Scope for PHM’s Intervention.

Given these challenges, the PHM can primarily engage with campaigns for inclusive health care and also the comparative use of other systems of medicine in particular areas. The people’s charter of health already recognised the role of health manpower development and strengthening the nursing cadre in India. Further the PHM is continuously questioning the content and nature of health services, and advocate for community participation and monitoring to ensure the quality.

The demystification of health care and the superiority of certain practices (for instance, curative aspects in Allopathy using drugs, surgery etc.) over other systems and practices (say, preventive and promotive aspects in Ayurveda, Yoga, Naturopathy etc. ) need to be carried out as part of the campaign. The documentation of best practices and efficacy of the other systems of medicine existing in different parts of the country needs to be undertaken. The media canvassing, exhibitions and discussions would be helpful in sensitizing public about people’s rights, ‘task-shifting’ approaches and recognition of other systems of medicine.

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