Redefining India’s health service through ‘Allied Health Professionals’ and need of a statutory regulatory body
In the past decade, a fundamental shift has occurred in healthcare delivery, largely due to advances in science and technology. There is now more recognition, than at any time in the past, that health service delivery is no longer just a prerogative of physicians and nurses. It is now a team effort, drawing upon the expertise of both clinicians and non-clinicians . These professionals or health-service providers were historically identified as ‘Paramedical staff’.
Better appreciation and utilization of the whole range of skills possessed by these paraprofessionals collectively termed as Allied Health Professionals (AHPs)—is the key to health-sector reforms in India, especially given the shortage of doctors and nurses in semi-urban and rural areas of the country. As the Indian government sets about reforming the public health sector and making universal health coverage a reality in India, the availability of qualified human resources for health has emerged as a significant challenge facing the healthcare delivery mechanism. There is an urgent need for the Indian government to plug policy gaps and ensure generation of adequate and effective human resources for health to provide quality care at primary, secondary and tertiary levels of health delivery in the country. There is a huge dearth of trained technologists/technicians in the system; advancement in technology in recent times demands trained individuals who can provide reliable results in conjunction with patient safety.
Globally, the incidence of non-communicable diseases (NCD) is steadily increasing and so in India, the heavy disease burden and the lack of access to healthcare will see the public health system face an NCD epidemic in the coming years. Public health facilities in India are unprepared as there are not enough specialists – clinicians and non-clinicians – to serve the entire country. The government is planning huge allocations for NCDs and for upgrading primary health centres with a focus on training personnel at this level to deal with future epidemics such as NCDs. Technologists and therapists will thus be required in huge numbers in the near future. Recent study undertaken by the Public Health Foundation of India (PHFI) for the Ministry of Health and Family Welfare (MoHFW) has indicated a supply-demand gap of about 65 lakh allied health professionals, when demand was calculated using basic international norms.
These Human Resources for Health (HRH) shortfalls have resulted in the uneven distribution of all cadres of health workers, medical colleges and allied health institutions across the states with wide disparity in the quality of education. The uneven distribution of professional colleges has led to a severe health system imbalance across the states, both in the production capacity and in the quality of education and training, leading to poor health outcomes.
The public health system in India suffers due to weak stewardship and oversight, HR shortages, weak HR management and ineffective service delivery. Doctors, Nurses and Allied health providers are in short supply for the populations they serve. The ratio is often skewed, resulting in fewer health providers in rural areas (especially in primary health centre settings), inefficient secondary services in smaller towns and a high concentration of tertiary health care services in urban cities. The skill mix, autonomy and funding of the medical bureaucracy at the district level need to be augmented, and initiatives for health need to be coordinated with efforts to address social determinants of health.
Many committees and experts have highlighted the importance of paramedics (allied health) in healthcare delivery in the past, including the National Knowledge Commission, which placed more importance in producing more AHPs over doctors, despite the acknowledged scarcity of the latter: “the opinion of 72 experts in the country over 40 years’ there is no need to increase the number of doctors but instead improve the quality and orientation of service provision towards better meeting the health needs of the people’ and that, ‘there is a dire need to focus on increasing the quantum and quality of human resources for nursing and paramedical/allied health services.”
Globally, there is mounting evidence that healthcare as a composite whole can only be improved if human resources for nursing and allied health services are developed, nurtured and enhanced in a systematic and planned manner. In India, there is a significant lack of standardization across medical education in general and in teaching advances in skills and technologies that emerged in the past decade, in particular.
In the case of AHPs, since the nomenclature for different categories of health professionals varies in different places, there is a considerable lack of clarity as to what constitutes a Paramedical or Allied health service e.g the nomenclature for entry post of Medical Technologist is Lab. Technician, Lab. Assistant, Biochemist, Scientist or Biomedical Scientist and what not. With a vast variety of allied health professions already present and with newer categories coming on board each day, India too, faces a similar challenge as different states have been using different definitions to describe this ever-growing field.
AHPs are woven into the fabric of public health in India. They are in the vanguard of creating a service based on people ‘being healthy’ rather than a service based on ‘fixing ill-health’. There is ample international evidence suggesting that empowered AHPs can be the leaders of change, playing critical role in improving the reach of health services in underserved areas.
With advancements in technology over the past few decades, the quality of medical care has vastly improved across the world. This has thrown up fresh challenges for the medical field. Today, there is an urgent need for competent people who can handle highly sophisticated medical machinery with competence. In fact, diagnosis has become so dependent on technology that the role of allied health staff has become vital in delivering successful treatment.
Several factors have contributed to the uneven power balance between doctors and AHPs. Medical dominance coupled with what is called “Medicalisation” is considered to be a major reason. Medicalisation, has not only broadened the scope of medicine but also raised its status. It reinforces the image of medical practitioners as being omniscient and omnipotent, rather it is a team work of Health care professionals. Medical dominance of healthcare has traditionally been the organising principle in the healthcare delivery system. 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. The clear hierarchy of occupations established through the growth of hospital medicine is attributed as a major contributor to the dominance of medicine in the division of labour. 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 the low morale and self-esteem among AHPs which needs to be addressed immediately if they were to contribute meaningfully to the well-being of people.
In many countries, notably the United States, the United Kingdom, Canada and Australia, policy rationalisations by their governments have facilitated the release of AHPs from medical dominance. 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 in the Foreword of the book Managing and Leading in the Allied Health Professions, makes a strong case for demedicalisation and eliminating medical dominance when he raises and answers several pertinent questions as follows.
- ‘Allied to what?’: ‘…the continual pursuit to relieve suffering for those we serve.’
- ‘In what way “professional”?’: ‘In the willingness to subordinate self-interest and prior assumptions to the pursuit of continual improvement in our effectiveness as a team, and to redraw the boundaries in the status quo.’
- ‘Why “health” and not “healthcare”?’: ‘To broaden the base of our capacity to serve.’
- ‘Are physicians, too, “allied health professionals”?’ ‘Of course. Why would you even bother to ask? We are all on the same team.’
‘Allied to what?’: ‘…the continual pursuit to relieve suffering for those we serve.’
‘In what way “professional”?’: ‘In the willingness to subordinate self-interest and prior assumptions to the pursuit of continual improvement in our effectiveness as a team, and to redraw the boundaries in the status quo.’
‘Why “health” and not “healthcare”?’: ‘To broaden the base of our capacity to serve.’
‘Are physicians, too, “allied health professionals”?’ ‘Of course. Why would you even bother to ask? We are all on the same team.’
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. Australia’s health system is managed not just by their doctors and nurses, but also by the 90,000 university-trained, autonomous AHPs vital to the system.
The recent modernisation of healthcare has initiated a team-based healthcare delivery model. Medical teams are usually ‘action teams’ due to their dynamic work conditions, wherein teamwork and collaboration are the pre-requisites for optimum results. The process of teamwork is inherently interdisciplinary, requiring a division of labour among the medical, nursing and allied health fraternity. Poor teamwork skills have been found to contribute to negative patient-care incidents. Not only is this team approach important for safe patient outcomes, it is also critical for efficient,cost-effective operations.
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 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. The role of regulating both the profession and professionals cannot be an optional path but rather a
condition for participation in the profession. It is therefore necessary to regulate these professions by setting up councils on the lines of the councils for Pharmacy, Nursing and other professions.
This council would be responsible, for the maintenance of uniform standards of education in the respective disciplines and the registration of qualified personnel to practice the profession. Currently setting up the new council has 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; and
- 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, the fruitful engagement of these associations remains to be explored. Lack of definitive and uniform criteria for faculty regarding essential qualifications for their classification, nomenclature, entry (direct versus lateral) and the absence of faculty development programmes perpetuate the challenges pertaining to the quantity and quality of AHPs. The availability of educational resources such as libraries, simulation centres and modern information technology tools at various centres is also variable. 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.
Extensive research by the Govt of India during the course of 12 months indicates the need for an overarching regulatory body for AHPs, excluding doctors, nurses, dentists and pharmacists. The Govt of India 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 standardization of education and putting in place quality control mechanisms for educational institutions, teaching methods, clinical protocols, workforce management
and any other related issues.
Standards and acceptable terminologies for the various professionals encompassing allied health starting must be established; with the group being referred to as Allied Health Professionals or AHPs in lieu of ‘paramedics’. A definition recently put forth by the Govt of India is thus: “Allied health professionals include 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 re-organisation of the various categories of AHPs based on educational levels and specialty qualifications to match international nomenclature and highlight their importance as vital team players in the healthcare delivery system. Standardised nomenclature is also recommended for AHPs as part of their career progression, so that promotional levels and associated pay grades may be normalised accordingly.
Courses should follow international standards so that they are widely accepted and receive worldwide recognition. Students passing out from colleges should be in great demand and get good jobs. The educational methods should lead to a product that is worthy of recruitment; therefore, it is very important to keep abreast of knowledge and maintain good liaison with the industry;
- Course delivery, practical training and assessments should be standardised.
- Committees should be formed to look into all aspects and standardisation.
- Standardisation should incorporate the demonstration of learning as well.
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 realized their potential and established several institutions and mechanisms to integrate these professions and professionals into the organised healthcare sector. However, the growing demand has resulted in the mushrooming of big and small institutions claiming to provide allied health education.
As the Ministry of Health and Family Welfare (MH&FW) 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 reintroduce these professionals into the public system to reap much-awaited rewards in the form of improved health outcomes for the Indian population.