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From Paramedics to Allied Health Sciences: landscaping the journey and way forward

Dec 21, 2012

In view of gaping shortages of doctors, allied healthcare professionals would have to play an increasingly prominent role in providing health services to India’s masses, says a report released by the Public Health Foundation of India today. Here is a brief overview of the report.

Advances in science and technology have inspired a fundamental shift in health care over the past decade resulting in wider appreciation of the fact that health service delivery must go beyond just physicians and nurses and involve team work among clinicians and non-clinicians or ‘paramedical staff.’ Better utilization of the whole range of the skills of para-professionals,or Allied Health Professionals (AHPs), is the key to health-sector reforms in India, particularly because of the shortage of doctors and nurses in its semi-urban and rural areas.

As the Indian government attempts to reform the public health sector and make universal health coverage a reality, the availability of qualified human resources has emerged as a significant challenge. There is an urgent need for the government to plug policy gaps and ensure the availability of the right human resources for quality care at primary, secondary and tertiary levels.

Given the growing spread of non-communicable diseases (NCD) globally, India could be up against an NCD epidemic in the coming years given the frailties in its health care system largely owing to the shortage of clinicians and non-clinicians. The government is making large investments to upgrade primary health centres with the stressbeing on training personnel to deal with future epidemics.

The overall human resource shortage has opened gaps within the existing infrastructure and services in the public sector and beyond. The HR crunch is aggravated by uneven distribution of health personnel and their attrition caused by insufficient investment in pre-service training, migration, work overload, inadequate growth opportunities and work environment issues.

India, currently suffers from the world’s highest number of maternal, new-born and child deaths. In 2008, 68,000 mothers and 1.8 million children under the age of five succumbed to maternal and child morbidity.Thus, in addition to the tribal population, mothers, infants and children constitute the majority of the underserved.

According to the latest World Health Statistics 2011 figures, the density per 10000 people in India is six doctors and 13 nurses and midwives working out to a doctor to population ratio of 0.5: 1000 in comparison to 0.3 in Thailand, 0.4 in Sri Lanka, 1.6 in China, 5.4 in the UK, and 5.5 in the United States of America.A recent Public Health Foundation of India (PHFI) study reveals a supply-demand gap of about 65 lakh allied health professionals.

These Human Resources for Health (HRH) shortfalls have resulted in the uneven distribution of all cadres of health workers, medical and nursing colleges, nursing and ANM (Auxiliary Nurse and Midwife) schools, and allied health institutions across states with wide disparity in the quality of education. The uneven distribution of professional colleges and schools has led to a severe health system imbalance across states, leading to poor health outcomes.

The public health system in India suffers from weak stewardship and oversight, HR shortages, weak HR management and ineffective service delivery particularly in rural areas. Secondary service in smaller towns is inadequate and tertiary care centres are concentrated in large cities. The skill mix, autonomy and funding of the medical bureaucracy at the district level need to be augmented and coordinated with efforts to address the social determinants of health initiatives.

Despite mounting global evidence that healthcare can improve only if human resources for nursing and allied health services are upgraded, in India there is a significant lack of standardization across medical education in general and in teaching recent advances in skills and technologies in particular. As for AHP, global statistics are unclear because they are defined differently in different countries.

AHPs in India provide are focused more on managing health rather than on ‘fixing ill-health’. There is ample international evidence suggesting that empowered AHPs can play a critical role in improving the reach of health services in underserved areas.The breadth and scope of the allied health practice encompasses the following:The age span of human development from neonate to old age; working with individuals with complex and challenging problems resulting from multi-system illnesses; working towards health promotion and injury prevention, and the assessment, management and evaluation of interventions; working in a broad range of settings from a patient's home to acute, primary and critical care settings; and having an understanding of healthcare issues associated with diverse cultures within society.

With advancements in technology the quality of medical care has vastly improved across the world, creating an urgent need for people who can handle highly sophisticated medical technology. With diagnosis depending on technology, the role of allied health staff has become vital for delivering successful treatment.

Many factors have contributed to the uneven power balance between doctors and AHPs. A phenomenon called “Medicalisation” has reinforced the image of medical practitioners as being omniscient and omnipotent, prompting societies to allocate continually growing proportions of their gross domestic product to their preferred healthcare services.

According to American academician and sociologist, Professor Eliot Freidson, medical dominance a concept linked to medicalization has at least three components:Trust, faith and confidence of the public in the medical profession; a position of authority based on exclusive command over a body of specialised knowledge; and dominance in the division of labour, that is, control over other health professions.Medical power is manifested through the professional autonomy of doctors, their pivotal role in the economics of the health services, their dominance over allied health occupational groups, administrative influence and the collective influence of medical associations.

Thus, high medical domination has been instrumental in lowering the status of AHPs in the eyes of people and is one of the reasons for their low morale and self-esteem, which needs to be addressed immediately if they are to contribute meaningfully to the well-being of people.

In many countries, notably the United States, the United Kingdom, Canada and Australia, government policy has freed AHPs from medical dominance. The Pew Health Professions Commission report (1995) observed: ‘the needs of the integrated systems will not be met simply by hiring public health professionals but by substantial and on-going retraining of nurses, physicians, allied health personnel and managers . . . [who are] required to apply the skills in new contexts.’’

Professor Donald M. Berwick, President and Chief Executive Officer, Institute for Health Care Improvement, and Clinical Professor of Paediatrics and Health Care Policy, Harvard Medical School makes a strong case for de-medicalisation and eliminating medical dominance in his Foreword to the book Managing and Leading in the Allied Health Professions.

Effective delivery of healthcare services depends largely on the nature of education, training and appropriate orientation towards community health of all categories of medical and health personnel and their capacity to function as an integrated team. For instance in the UK, more than 84,000 AHPs, with a range of skills and expertise, play key roles within the National Health Service. Though some of them may have a PhD and use the title ‘Dr’ they are not medically qualified. All of them are first-contact practitioners and work across a wide range of locations and sectors within acute, primary and community care. Australia’s health system is managed not just by their doctors and nurses, but also by 90,000 university-trained, autonomous AHPs.

The modernisation of healthcare has spawned a team-based healthcare delivery model, wherein teamwork and collaboration are necessary for optimum results. The process of teamwork is inherently interdisciplinary, requiring a division of labour among the medical, nursing and allied health fraternity.Not only is this team approach important for safe patient outcomes, it is also critical for efficient, cost-effective operations. Let’s take a case in point at the William Harvey Hospital, East Kent Hospitals of the NHS Trust, where an accident and emergency assessment team is made up of an occupational therapist, a physiotherapist and a care manager. The team provides a full functional and social care assessment for frail elderly patients who arrive at theAccident and Emergency department in Ashford. The team’s immediate care package often allows patients to return home immediately to more appropriate care, with the support of an occupational therapist.

‘The team believes that ‘patients have benefited because the decision-making is better and faster. We can now see the whole picture; our care is much more holistic. As a team we have the most appropriate skills to make the best decisions on whether a patient can go home safely or should be admitted to hospital.’

Currently, due to the absence of a central regulatory authority for allied health professionals and courses in India, they are divided into smaller groups, appearing to be ‘regulated’ by independent professional bodies at national and state levels. For instance, the rules or norms of professional practice vary from extremely professional and well-organised groups such as physiotherapists, optometrists and speech and audiology professionals to diffused groups such as operating room technicians and radiation therapists.

For the allied health cadre to grow in the healthcare system, these professional associations need to be bound by a common authority that will help the AHPs to flourish as a family rather than different classes within the community of the healthcare system. As a rule both the profession and professionals need to be regulated. In 2007, the government of India proposed setting up separate councils for medical laboratory technicians, radiology technicians, and physiotherapists/occupational therapistsfor the maintenance of uniform standards of education in their respective disciplines and the registration of qualified personnel to practice them.

A representative of the MoHFW apprised the Parliamentary Standing Committee on Health and Family Welfare about the circumstances that necessitated the firming up of a Bill to set up the new council.  He pointed out the following problem areas, which require regulation at the earliest:

Para-medical professions are not regulated
Entry-level qualifications are different at different levels
Level of knowledge and skills is not uniform, since the period of training differs from place to place and has no uniformity
Course curricula are not uniform
Fee structure and facilities in these institutions are not regulated
Ethical standards are not uniform and are not being enforced

The lack of planned courses and institutions, non-uniform nomenclature for the existing courses, diverse standards of practice and lack of qualified faculty pose a threat to the quality of education and skills of the AHP in India. Although there are professional associations for certain AHPs, for example, the Indian Optometric Association and the Indian Occupational Therapy Association, the fruitful engagement of these associations remains to be explored.
Moreover, while established centres managed by large medical institutions offer a reasonable level of facilities, the educational resources are abysmal in stand-alone centres or smaller set-ups.

The Confederation of Indian Industry (CII) believes that ‘private partners can play a key role in capacity building and training through PPP modes to better utilise the infrastructure of government hospitals. The government can encourage private sector interest through tax incentives and permits to corporates to undertake healthcare for optimised use of resources. For example, a medical college with a 500-bed capacity could produce 150 students annually, instead of the 100 as per the current MCI norms.’ A CII policy paper points out that ‘capacity building and training initiatives by the government need sharpened focus not only for a quantitative increase in trained manpower but also for improving the effectiveness of existing methods in training’.

Extensive research by the PHFI team during the course of 12 months indicates the need for an over-arching regulatory body for AHPs, excluding doctors, nurses, dentists and pharmacists. The PHFI team has recommended the establishment of national and regional institutes for allied health sciences, dedicated to nurturing and retaining talent in the allied health space. In the absence of a Council, this could be an interim multi-stakeholder body comprised of experts from different allied health professions, administrative leadership and even patients. This body would be responsible for ensuring standardisation of education and putting in place quality control mechanisms for educational institutions, teaching methods, clinical protocols, workforce management and any other related issues.  

According to a PHFI definition the term AHP  “includes individuals involved with the delivery of health or related services, with expertise in therapeutic, diagnostic, curative, preventive and rehabilitative interventions. They work in interdisciplinary health teams including physicians, nurses and public health officials to promote, protect, treat and/or manage a person’s physical, mental, social, emotional and environmental health and holistic well-being”

In addition, it is critical to undertake a complete reorganisation of the various categories of AHPs based on their educational levels and specialty qualifications to match international nomenclature and highlight their importance as vital team players in the healthcare delivery system. Courses should follow international standards so that they are widely accepted and globally recognized. Students passing out from colleges should be in great demand and get good jobs.

Committees should be formed to look into all aspects and standardisation. Each institution conducting courses on allied health should analyse and keep a record of the student base. This should consist of key statistics and qualitative information such as demographics and the type of applicants for each course, the number that are selected, enrolled and those that ultimately graduate, and the number of drop-outs each year by specialty. This will help generate a better picture of the supply demand issues for the future. Strategies should be developed to create flexibility in course delivery through alternative delivery modes, multiple locations and timings.

There is also a need to look at options for fast education especially for persons with experience but without adequate qualifications. Additionally, short term educational programmes need to be put in place for those who have a basic education such as a B.Sc. degree in any science subject and want to pursue a career in allied health sciences.

For each course, centres of excellence and globally recognised institutions should be identified along with hospitals with known good practices, which may become possible training sites. Those institutions willing to conduct courses or to become training sites should be incentivised by the government. It is important to motivate both government and private institutions to conduct courses at various levels (diploma to post-graduate and doctoral) depending on their capacities, thus increasing the number of courses in various streams and the students for each course. However, if this is not possible, then they should be motivated to at least become clinical training sites rendering quality education to students.

Quality improvement can be implemented by establishing partnerships with international institutions of excellence and PPPs to bring out the best in the profession. The standards developed at the centre and state levels should be in complete harmony with each other. Emphasis on research activities needs to be enhanced and funding provided at regular intervals either by the centre, state or foreign direct investment for the development of the research centres.Along with the applicability of the desired means to augment capacity, it is also essential to focus on quality education. The Government will need to develop a number of options to encourage flexibility in allied health sciences’ education without compromising on its quality. Improvement in infrastructure and availability of faculty is a challenge that needs to be addressed.

There is a need to define a pathway of an upgraded lateral entry within the allied health educational universe, such as for a diploma holder to enter a degree programme. All avenues for each level of transition should be defined. With respect to public awareness, candidates should be well-versed with the difference in opting for any degree or diploma programme.

Robust Public Private Partnership (PPP) models need to be established for the training of faculty and ensuring that the required numbers of students graduate each year. Some incentive or financial support should be provided to start these courses. Strengthening community colleges in terms of proper committees and faculty, and following standards is essential. It is also necessary that recognition by the Union Ministry of Human Resources Development and the Directorate of Employment as well as training by the respective State governments be carried out so that the students from these colleges get national and regional acceptance.

The Path Forward

The national initiative for allied health sciences aims to convert academic arguments for strengthening allied health sciences into politically articulate policies that help in capacity building and value realization of allied health professionals in the healthcare delivery system.
Nine premier institutions (eight RIAHS and one NIAHS) will be the lead technical resources for education and training of students. Providing education on such a scale would involve extensive collaboration among various stakeholders at the Centre, state and intra-state levels. The initiative may be introduced in a phased manner. Activities will include setting up National and Regional Institutes of Allied Health Sciences (NIAHS and RIAHS), establishing interim regulatory mechanisms in order to standardize curricula and training programmes and developing faculty across India in the allied health streams, while engaging a network of institutions, as indicated in Chapter 3. Thus, the implementation arrangements would also require the establishment of management structures at the national, state and institutional levels.

There is also a need to form a task force for curriculum development cells in existing universities, which will be affiliated to project institutions and spread best practices to non-project institutions. There is a need to establish industry–institute partnership promotion cells, along with sharing of best academic, administrative and governance practices through workshops and specific groups.

The NBAHS will be responsible for overall monitoring of allied health education and practice in the country, and its coordination with other Ministries/ Departments and the All India Council for Technical Education (AICTE). The Board will be supported by two committees under it; the National Allied Health Education Committee (NAHEC) and National Allied Health Evaluation and Assessment Committee (NAHEAC) to ensure that standard and acceptable terminologies are used for the various professionals in allied health.

To conclude, Allied Health Professionals (AHPs) constitute a vital part of the health system delivery, both nationally and internationally. In the Indian context, however, their significance and role has been marginalised due to the prevalent culture of medical dominance and the lack of a statutory body to give prominence to their contributions and concerns.

Allied health workers are an untapped treasure, critical to fixing the gaping holes in India's health workforce, particularly the severe shortage of physicians and specialists. It would be a grave mistake to not utilise the capacities of this resource at a time when the government is bringing in critical reforms in public health and aiming to improve access to health by focussing on preventive, promotive, curative and rehabilitative needs of the population. While the government is considering strategies to best utilize AHPs, the private sector has realised their potential and established several institutions and mechanisms to integrate these professions and professionals into the organised healthcare sector.

As the Ministry of Health and Family Welfare in India gets ready to undertake a facelift for the entire allied health workforce by establishing national and regional institutes of excellence, the time is opportune for the government to study this provider group in detail; review existing inputs, processes and outputs; standardise institutions, educational tools and methods; revisit career paths and progression; and re-introduce these professionals into the public system to reap much-awaited rewards in the form of improved health outcomes for the population.

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