Gaudium Foundation – Is the auxiliary healthcare providers like mid-wives and nurses adequately trained? – A Sneak Peek into The State of Their Training

The Auxiliary Healthcare System in India

In a country that faces an acute shortage of health personnel coupled with severe inequalities in the distribution of health workers, informal health providers in the shape of auxiliary healthcare staff remain a mainstay of the primary care system, addressing more than 70% of the primary care needs. These informal practitioners, who form a majority of the rural healthcare staff, continue to operate without any formal medical training as the first-source of primary care. They address medical needs in areas where the government facilities are less accessible. However, it remains a matter of debate even today whether this auxiliary staff ought to be integrated into the health system.

The allied healthcare professionals’ workforce, that includes individuals involved in the delivery of holistic health and well-being, plays a critical role as the foundation stones of the healthcare system as well as in the achievement of sustainable human and economic development. However, like in most developing countries, in India too, the acute shortage of trained healthcare workers impedes progress towards development goals, despite the availability of some very effective interventions. In addition to this known shortage, these are large-scale inequalities in the distribution of the available pool of medical workforce too. These factors make the healthcare system incapable to meet the health demands of the population.

In such a scenario, there is a marked need to augment the competency of healthcare workers at the various levels and ensure that quality and improved access to healthcare services is made available for a universal health coverage.

Availability & Production of the Auxiliary Healthcare Staff

India’s health workforce combines both the registered, formal health-care providers and a larger pool of informal health workforce. The rural healthcare system comprises mostly of sub-centers manned by auxiliary nurse midwives and trained health practitioners and serving up to 5000 people. In addition, the Primary Health Centers and Community Health Centers serve as the point-of-contact between the rural communities and medical staff supported by medical officers and paramedic staffs. However, despite being one of the most important source of global health workforce market, inequalities in the availability of health workers as well as the dearth of skilled birth attendants, especially in the rural context, have become a given in the Indian healthcare landscape.

Although the production and availability of the frontline health workers such as the auxiliary nurse midwife (ANM), has expanded significantly in recent years, workforce shortage and the imbalances in their distribution continue to be substantial, especially when it comes to appropriately trained, motivated and supported health workers. These shortages exist due to lack of basic amenities such as electricity, lack of professional development opportunities, and even basic medical resources, deter educated health workers from serving in the rural areas. For a country that is primarily rural, this marks the death of the maternal healthcare dream.

Role of Training in Production of Auxiliary Healthcare Staff

With changing times, however, the role and capacity of the ANM has also transformed into that of a multi-purpose worker involved in the various phases of implementation of the national health programs, besides the provision of delivery and curative services. However, this transformation has impacted the quality of nursing and midwifery education resulting in loss of skills as well.

The role of training in the production and sustenance of the auxiliary healthcare system cannot be downplayed. Nurses and other allied healthcare staff are but an integral part of a collaborative healthcare delivery machinery. Higher nursing and auxiliary healthcare education in the principles and practices of nursing goes a long way in providing opportunities for them to become a part of the development of the rural medical communities and serve as competent administrators and registered qualified nurses in healthcare facilities. Training also helps in bridging the gap in the availability of healthcare providers through improving their quality of medical attention and addressing the acute paucity of trained healthcare personnel. Auxiliary staff trained in midwifery helps in establishing and sustaining well-functioning facilities equipped with all the basic obstetric medical supplies.

In fact, in addition to these basic services, well-trained birth attendants and midwives also play a crucial role in stemming maternal deaths and improving maternal health through continuum care through increased referral capacity for managing complications. Training and supervision using participatory training provides a tool for monitoring and measuring maternal mortality initiatives. Thus, maintaining and enhancing the knowledge and skill-base of midwives and nurses through retraining and reinforcement is the key to maintaining the maternal-child health that is required to prevent maternal and infant mortality.

Implementation of comprehensive training programs also works as a key strategy in the promotion of healthcare services and in the improvement of essential practices like immediate assessment of newborns, thus contributing to an improved mother and child healthcare. In fact, findings suggest a considerable improvement in the mother -child healthcare between pre-training and post-training periods, even among experienced midwives with earlier formal education.

State of Training in India

Since Independence, the Government of India has been in the process of unification of the nursing and midwifery professionals into the mainstream healthcare delivery system. From creating a regulatory body to control and regulate training of nurses and midwives (Indian Nursing Council) to expansion of medical and nursing colleges and introduction of courses such as (a) General Nursing and Midwifery (GNM); and (b) ANM course, India has made every effort to strengthen the midwifery training, cadre and services.

However, despite these initiatives, the remains room for tremendous improvement in health-care delivery through the availability of skilled and motivated health workers. Review of the existing data on training of health workers highlights the rapid expansion in the training capacity of health workers between 1991 and 2013, with the number of admissions to nursing colleges increasing by a whopping threefold time. In addition, the last decade has also witnessed a notable increase in the involvement of the private sector in medical and nursing education, thus establishing a tremendous and progressive increase in the training capacity. This privatization of medical education has also helped in overcoming the shortfalls in the expansion of the training capacity in the public sector.

However, the Indian healthcare system is blighted by gross inequalities in the distribution of the training institutes among the different states, mainly being cluttered in states with high GDPs rather than the economically disadvantages states. Further, there is also a mismatch between the vacancies in the public health system and the rapid growth in the production of healthcare workers such as nurses and midwives. Not only this, almost three-fourth of the providers have no formal training and education on maternal health. Thus, there exists an urgent need for a sustained and innovative action-plan that would address India’s existing health-workforce crisis.

Undoubtedly, this imbalance is not just affecting the production capacity of the health workforce, but also impacting the quality of training of these providers, leading to poor health outcomes.

Policy Initiatives to Improve Training

A permanent solution to the problem of poor rural health care in India warrants steps to improve training among the auxiliary healthcare staff. Over the past few decades, the central and state governments have moved towards this critical force in improving healthcare in a concerted way.

From implementing strategies that include compulsory rural postings to government health facilities, incentivizing rural postings and linking rural postings to admission to postgraduate medical courses, and investing in medical infrastructure and manpower, the government is making strides in addressing these inequities and ensuring that these professionals are being trained in the milieu of the healthcare set ups where they are likely to serve. The government has also increased its spending in health and offers higher salaries and other peripheral facilities for MBBS degree holders to encourage them to work in villages.

Towards this end, both the central and state governments are provisioning for accessible, affordable and quality healthcare services through the implementation of key training programs under the aegis of its broader strategy that covers reproductive, maternal, infant, child and adolescent health. Some of the key programs include:

Jan Swasthya Sahyog launched in 2011 to initiate training of nurses
Launching training programs such as Auxiliary Nurse Midwives (ANM) and General Nurse Midwives (GNM).
Micronutrient Initiative (MI) that provides technical expertise on training healthcare providers and beneficiaries with IEC/BCC, along with improved program monitoring and evaluation.
As a long-term measure, the Ministry of Health proposed a new BSc course in Community Health as an initiative to train primary health-care providers, however the proposal was later turned down by IMA.
The National Rural Health Mission has set training as a high priority mission with a total amount of Rs. 741,500 earmarked for training for the 100 ASHAs alone. In districts with 12-15 blocks, about Rs. 1-crorehas been made available for training of ASHAs.
The Health and Family Welfare Ministry has also initiated a centrally-sponsored scheme that would establishe the ‘National Board for Allied Health Sciences’ to oversee the creation of five Regional and one National-level Institute of Allied Health Sciences with a view to developing an allied health system to ensure standardization of allied healthcare education.

In India, the success of any of the myriad public health programs relies heavily on the frontline healthcare providers and these programs serve to play a pivotal role in the improvement in access to healthcare and nutrition.

Counteracting Challenges

The dismal state of rural healthcare machinery, blighted by the paucity of healthcare facilities, medical professionals and paramedic staff is further pronounced by the predominance of untrained healthcare practitioners that serve as the first point of primary care. The efforts of increasing the healthcare facilities have paid off, but access to medical staff remains a challenge. Auxiliary staff such as radiation therapists and other allied health professionals play a pivotal role in this machinery. Thus, it becomes important to not just build their capacity but also ensure that they are appropriately skilled to manage critical patients.

A major constraint in their training lies in the lack of standardization curricula, courses and training methods, an absence of an overarching regulatory structure such as the MCI/INC, limited job opportunities and unclear career paths. The lack of training among nurses and allied health professionals makes not just the primary healthcare services, but even the secondary and tertiary care, severely doctor-dependent. Planning for health professional education should provision for these roadblocks and efficiently utilize the existing manpower within the auxiliary healthcare staff to combat this problem.

Conclusion

In conclusion, it cannot be denied that the informal sector practitioners serve as a critical link in tackling the ever-increasing burden of maternity complications and play a pivotal role in the holistic maternal care. To add to this, the scarcity of medical doctors makes it important that these auxiliary healthcare professionals are empowered with adequate training to increase their efficiency and enable them to reach out to the larger population with the healthcare services.

Ensuring their training helps not only reduce the cost of care, but also serves as a well-proven strategy to improve accessibility and affordability of quality healthcare services. And, though there is no getting away from the ever-present need of more doctors serving the rural communities, it is important to accept the presence of the auxiliary healthcare providers and manage them through formal training to enhance their abilities to serve the specialized care needs of maternal health.

In recent times, the rapidly evolving healthcare delivery machinery makes it imperative that there be a concerted team effort, thus necessitating a larger focus on a multidisciplinary team approach that involves a large pool of trained auxiliary healthcare providers. These empowered allied health workers can become the leaders of change, playing life-altering roles in the implementation of sustainable change and improvement in the reach of health services in under-served areas.

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