Task shifting in health care: the risks of integrated medicine in India
Authors: Satchit Balsari, Greg Simon, Rajalakshmi Nair, Sujata Saunik, Mrudula Phadke
Journal: The Lancet Global Health (2017)

Health care in India has rapidly transformed in the past two decades, with state-of-the-art private hospitals expanding in urban areas in particular. The demand for trained allopathic physicians with MBBS degrees has far outstripped supply, and institutions have responded by recruiting graduates from India's traditional streams of medicine (so-called AYUSH doctors) to staff these hospitals. AYUSH doctors are trained in either Ayurveda, Yoga, Unani, Siddhi or Homeopathic medicine, some for up to 5 years.1Rao M Rao KD Kumar AS Chatterjee M Sundararaman T Human resources for health in India.Lancet. 2011; 377: 587-598Summary Full Text Full Text PDF PubMed Scopus (249) Google Scholar Although they have little to no formal education in modern allopathic medicine, these doctors commonly staff wards and intensive care units in some of India's largest private hospitals, informally learning their trade by apprenticing on the job, unregulated and unmonitored by any professional medical organisation. Such opportunistic task shifting is not new to the medical system in India, where health-care delivery in rural areas has largely—and legally—depended on the services of community health workers and AYUSH doctors. Consistent with these trends, the Health Ministry has shown interest in launching an integrated curriculum that supplements traditional medicine with allopathic practice.2Hindustan TimesMedical studies: Govt plans to tweak undergraduate course, combine traditional and modern medicine.http://www.hindustantimes.com/india-news/govt-mulls-modifying-undergrad-medical-curricula-to-boost-integrative-medicine/story-qKa3wfDO4QqwxUL2d70aqM.htmlDate: June 19, 2017Google Scholar In December, 2016, the state government of Madhya Pradesh, India's fifth largest state with a population of over 75 million people, announced a 3-month course that will allow Ayurvedic and Unani doctors to practice allopathic medicine in government-run health-care centres, and prescribe from a finite inventory of 72 medicines.3Medical DialoguesBill passed: Ayurveda, Unani doctors can practice modern medicine in MP.http://medicaldialogues.in/bill-passed-ayurveda-unani-doctors-can-practice-modern-medicine-in-mp/Date: 2016Google Scholar There will probably be substantial resistance from professional allopathic medical organisations, citing concerns of dilution of care. Similar courses and task shifting initiatives among physicians have been previously tried elsewhere in India, and have failed. Following a pilot programme in Gujarat in 2005, the Government of India launched a nationwide initiative to train MBBS doctors in focused obstetric care to allow them to conduct caesarean sections in rural India, where there are no specialists. A concomitant programme, Life Saving Anaesthetic Skills for Emergency, was also launched in 2006.4Mavalankar D Callahan K Sriram V Singh P Desai A Where there is no anesthetist—increasing capacity for emergency obstetric care in rural India: an evaluation of a pilot program to train general doctors.Int J Gynaecol Obstet. 2009; 107: 283-338Crossref PubMed Scopus (15) Google Scholar The programmes were poorly planned, failed to assign doctors trained in caesarean sections or anaesthetic skills to the same location, did not offer the candidates adequate bedside training or continued mentorship, and failed to provide incentives or pathways for career progression. Both programmes were discontinued. Similarly, the states of Chhattisgarh and Assam launched abridged training programmes in medicine to train new rural health practitioners and medical assistants.5Raha S Bossert T Vujicic M Political economy of health workforce policy.http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/ChattisgarhCase.pdfDate: 2010Google Scholar Despite substantial state sponsorship, these programmes were also discontinued because of an absence of adequate stakeholder consensus about the role and scope of their practice, and thus, any sustained employment opportunities for them. India need look no further than its villages for successful models of task shifting. Global practices in home-based neonatal care are based on scientific evidence from care provided by trained local community health workers in tribal India.6Bang AT Bang RA Baitule SB Reddy MH Deshmukh MD Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India.Lancet. 1999; 354: 1955-1961Summary Full Text Full Text PDF PubMed Scopus (585) Google Scholar The success of these community-based task shifting interventions in reducing infant malnutrition and maternal and child morbidity and mortality relies on robust training programmes, reliable peer support, referral networks, and sustainable incentives.7Satav A Effect of home based child care & nutrition improvement program on child mortality and malnutrition in a tribal belt: result of field randomized control trial.https://www.omicsonline.org/2375-4273/2375-4273-IndoGlobalHealthcare-2015_ScientificTracks-Abstracts.digital/#?page=46Date: 2015Google Scholar In line with evidence-based practice, the programmes have been regularly monitored, evaluated, and modified. The government's National Rural Health Mission has also trained over 850 000 accredited social health activists (typically women from village communities) in a range of clinical and preventive medicine skills, making them a crucial part of health-care delivery in rural India. Accredited social health activists work on an incentive-based model and electronically log the daily services they provide. Prompt expansion of health-care providers in India is needed. India has about 12 allopathic doctors, nurses, and midwives per 10 000 people, which is less than half of the WHO benchmark of 25·4 workers.8United States Agency for International DevelopmentStrengthening India's public health workforce: a landscape analysis of initiatives and challenges.http://www.chwcentral.org/sites/default/files/Strengthening-Indias-Public-Health-Workforce%20%281%29.pdfDate: 2014Google Scholar Although task shifting has been presented as a solution to some health-care demands in rural India, retraining of AYUSH doctors is typically met with resistance. The Indian Medical Association and the Medical Council of India have launched several legal battles to challenge the government's permissive approach to redefining the scope of care provided by AYUSH doctors.9Sharma DC India still struggles with rural doctor shortages.Lancet. 2015; 386: 2381-2382Summary Full Text Full Text PDF PubMed Scopus (51) Google Scholar We encourage the inclusion of AYUSH doctors into the delivery of allopathic care, but propose that this training is reimagined as a task shifting initiative, rather than merely a jurisdictional battle of clinical privileges. A consensus on the scope of care provided by AYUSH doctors is urgently needed. Although community workers typically have no more than a few preconceived notions of home-based remedies, AYUSH doctors have many years of training and experience that might—or might not—be in direct conflict with allopathic medicine. Particularly at the primary care level, it might be inevitable that AYUSH doctors want to continue to practice traditional medicine as well. Such integrated practice, if permitted, would need to be grounded in modern science. To date, evidence supporting the efficacy or safety of such integrated practice is wholly absent. Integrated curricula will require many years of randomised clinical trials that combine traditional and modern medicines and practice. Policy makers and politicians will probably opt for shorter timelines to demonstrate expedient effects. As the Union Ministry of Health and various state governments review proposals for AYUSH expansion and the integration of disparate streams of medicine, we would like to highlight the need for a clear definition of clinical or public health objectives of such task shifting. Integration of disparate medical streams without due diligence and scientific rigour will put the wellbeing of millions of patients at risk. Integrated curricula might need to be highly protocolised, and clinical practice will probably be monitored and regulated with the aid of digital technology and health information systems. Plans and budgets for continued support, referral networks, incentivisation, monitoring and evaluation, and opportunities for career progression are crucial to the success of such an initiative.10WHOTask shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines.http://apps.who.int/iris/bitstream/10665/43821/1/9789241596312_eng.pdfDate: 2007Google Scholar The inclusion of AYUSH providers in the delivery of allopathic medicine could be one of the largest task-shifting enterprises the Indian government undertakes. For it to achieve the desired effect on the delivery and quality of health care, its execution should be carefully planned. MP is a senior adviser and SS a senior policy maker in the Government of Maharashtra. Workshops and discussions among various stakeholders were facilitated by RN at Unicef Mumbai. We declare no other competing interests.