The latest move by the Government of Karnataka to utilise the services of Ayurveda, Yoga, Unani, Siddha and Homoeopathy (AYUSH) practitioners by permitting them to prescribe modern or allopathic medicines is debatable. The Government proposes to provide them 18 months training on modern (emergency) medicine and legally authorise them to prescribe them especially in rural areas.
This is not the first attempt. Citing the shortage of modern or allopathic doctors, the Government of Maharashtra too proposed to allow the AYUSH doctors to prescribe allopathic medicines after a one year course in pharmacology. The Central Council of Indian Medicine (CCIM) said “Indian medicine practitioners would soon be allowed to prescribe 68 allopathic medicines in emergencies under National Rural Health Mission”. The present article is not intended to examine its legality but to explore a better alternative of utilizing the services of qualified pharmacists in primary health care.
Even though India failed to achieve “Health for All by 2000” as a part of signatory to 1978 Alma-Ata declaration, India now propose to achieve Universal Health Coverage (UHC). The 2005 World health Assembly has urged the member states to pursue the agenda of universal health coverage.
The country defines the aim of universal health coverage as to ensure equitable access for all Indian citizens to affordable, accountable, appropriate health services of assured quality. The Planning Commission of India has identified the availability of trained and skilled health workforce as one of the prerequisite for achieving UHC. While World Health Organization (WHO) endorsed a threshold level of 23 health work force (doctor, nurse and midwives) per 10000 populations, India is reported to have just 19 for 10000.
The figure for physician is six per 10 thousand against the WHO’s recommendation of 10. In addition there has been skewing distribution of doctors. The study has shown that only 26 per cent of the doctors resided in rural areas serving 72 per cent of the total population of the country (2006). The study has also shown that the urban density of doctors is nearly four times that of in rural areas. This shows the acute shortage of doctors in rural belts of India. In absence or acute shortage of doctors, it is a matter of imagination how the healthcare is met.
The Government has proposed to initiate Bachelor of Rural Health Care (BRHC), a three year non-MBBS course in an attempt to make adequate trained health professionals available in rural areas where modern medicine qualified physicians do not prefer to serve. The Government’s compulsory rural posting idea has been fought tooth and nail by the medical students. The BRHC course too opposed.
The initial idea of BRHC is now taken the form of BSc (Community Health). The Government of India is even issued contempt of court order by the Delhi High Court for failing to comply with court’s earlier order to start three year course for non-MBBS persons to practice medicine in rural areas. The clinicians with three years of training in allopathic medicines are in operation in two states: Rural medical Assistants at PHC in Chhattisgarh and Rural Health Practitioners in Assam.
The pharmacy programme in India is available at various levels. The Diploma in Pharmacy, Master of Pharmacy (Pharmacy Practice) and Doctor of Pharmacy programmes are clinically oriented pharmacy programmes. They are trained not only in pharmacology of drugs but also in basic health sciences like human anatomy, physiology, biochemistry. The Doctor of Pharmacy (PharmD), a six year programme, intends to prepare pharmacists to have adequate knowledge and expertise in the area of therapeutics, disease process, selecting the most cost effective medical intervention, and strong communication skills. The training in hospital’s clinical environment for six years makes the PharmD pharmacists very suitable to be utilized as a better alternate to non-medical physicians.
Globally there have been attempts to improve healthcare through empowering other group of health professionals to serve as non-medical physicians. The nurses and the pharmacists are trained and legally permitted for expanded services. There are at least 22 countries that have legislation providing prescribing authority to nurses. In UK, the pharmacists were given initially limited right of prescribing and later since 2006, they are given power as independent prescribers who can prescribe any licensed medicines except controlled drugs. The US is a pioneer in utilizing the services of pharmacists in healthcare and has permitted them to have limited dependent prescribing to independent prescribing and initiate therapy depending on states.
The Government explores option of utilizing the services AYUSH doctors. But there is a pool of qualified pharmacy professionals with adequate knowledge of modern medicines is being ignored. The pharmacists in the government sectors working in rural areas are often in charge of primary care centres when the lone doctor goes on leave. They do continue serving even in absence of doctor. Legal or illegal seems to be of no issue. When the patients come, they cannot be sent back just because doctor is on leave. The pharmacists in urban area especially in retail pharmacy too provide services to many who cannot afford for medical consultation. These poor and vulnerable groups find the neighbourhood pharmacy as their healthcare centre.
Yes, there are issues. But the issues can be suitably addressed by providing little more training on diagnosis of minor ailments and to understand when to refer for medical advice. Empowering the pharmacists for treating the patients at primary care level can be viewed as an alternative model of improving the density of health care professionals’ especially in rural areas and benefiting millions. The model is worth exploring, at least experimentally in some areas, which would help in achieving the ambitious universal health coverage in India.
With rising population, increasing longevity, and increasing demand of healthcare, there would be increasingly shortage of medically qualified physicians. With limited spending in public health the budget gets stretched further. This necessitates the innovative thinking of optimally utilizing the skills of different professionals. Perhaps one of the workable ideas is to delegate the tasks now undertaken by physicians to pharmacists and nurses at least in primary care to begin with.
(Authors are faculty Department of Pharmacy,
Annamalai University, Annamalai Nagar)