deprofessionalisation globally in the field of health

1. Deprofessionalisation of
medicine
Dr Anupkumar T N
Junior Resident
Dept of Community Medicine
Govt Medical College,Thrissur

2. Outline
• Heath professional
• Definition
• Available human resources
• Concept of community health workers
• Indian scenario
• What is happening in Kerala?
• Strength and weakness
• References

3. A health professional, health
practitioner or healthcare provider

4. • A health professional may operate within all
branches of health care
• A health professional may also be
a public/community health expert working for
the common good of the society

5. MEDICAL VIEW POINT
• A ‘condition’ in which autonomy—
defining characteristic of a professional
is lost by a professional
• Doctor-patient relationships, patients as
consumer

6. • Customers and service providers
• No longer are as free as we once were,
(and we are losing more and more of what
freedom remains), to act in the best interests
of our patients

7. PUBLIC HEALTH VIEW
• To make health services meaningful
• Within the easy reach of the common man

8. HEALTH WORK FORCE

11. • The global health work force 59 million
workers
• Health service providers account for 67% of all
health workers globally
• Income wise variation among countries
• Over 70% of doctors and over 50% of other
types of health service providers
• The proportion of female doctors in Europe
increased steadily during the 1990s

12. • The number of nurses per 1000 doctors for a
typical country is highest in the WHO African
Region
• WHO estimates a shortage of more than 4
million doctors, nurses, midwives and others
• Shortages are not universal, even across low
income countries

19. • United States- the federal budget invested
$330 million
• Canada-the 2011 federal budget announced
a Canada student loan forgiveness programme
• Uganda- 50% staff positions are vacant

20. WHO REPORT
• A shortage of almost 4.3 million doctors,
midwives, nurses, and support workers
worldwide.
• The shortage is reported most severe in 57 of
the poorest countries, especially in sub-
Saharan Africa
• An estimated 1 billion people will never see a
health worker during the course of their lives

21. HEALTH CARE MODELS

22. BAREFOOT DOCTORS
• Mao Zedong's healthcare speech in 1965
• Urban bias of the medical system of the time,
• Called for a system with greater focus on the
well being of the rural population
• 1968, the barefoot doctors program became
integrated into national policy
• By 1977 there were over 1.7 million barefoot
doctors

23. • Farmers who received
minimal basic medical
and paramedicaltraining.
• to bring health care to rural
areas where urban-trained
doctors would not settle.
• Promoted
basic hygiene, preventive
health care, and family
planning and treated
common illnesses

25. • Building Resources Across Communities
• Bangladesh Rehabilitation Assistance
Committee
• Bangladesh Rural Advancement Committee
1972
• BRAC is present in all 64 districts of
Bangladesh as well as 13 other countries in
Asia, Africa, and the Americas.

26. • BRAC employs over 100,000 people, roughly 70
percent of whom are women, reaching more
than 126 million people
• The organisation is 70–80% self-funded through a
number of social enterprises.
• BRAC has operations in 14 countries of the world
• In 1979, BRAC entered the health field by
establishing a nationwide Oral Therapy Extension
Programme (OTEP

27. BRAZILIAN MODEL
• Family Health Program in the 1990s that made
use of large numbers of community health agents
• . Between 1990 and 2002 the infant mortality
rate dropped from about 50 per 1000 live births
to 29.2
• During that period the Family Health Program
increased its coverage of the population from 0
to 36%.
• The largest impact appeared to be a reduction of
deaths from diarrhea

28. IRAN
• Para-professionals called behvarz
• These workers are from the community and are
based in 14,000 "health houses" nationwide
• They visit the homes of the underserved
providing vaccinations and monitoring child
growth
• Between 1984 and 2000 Iran was able to cut
its infant mortality in half and raise immunization
rates from 20 to 95%.
• Fertility has dropped from 5.6 lifetime children
per woman in 1985 to 2 in 2000.

29. OTHERS
• In sub-Saharan Africa, Community
HealthWorkers are trained to provide basic
medical and preventive care.
• In Liberia,Tanzania,Mali also community
worker model successful.
• In Newyork CHW s for chronic diseases
• In Asia also LHW,ASHA,CHW.

30. INDIAN SCENARIO

31. • India has only six doctors for a population of
10,000 (1:1674)
• 13 nurses and midwives per 10,000, against
WHO‘s recommendation of a minimum 23
health workers per 10,000 to ensure coverage
of essential health services.
• Almost 74% of India‘s doctors are
concentrated in cities, where only 28% of the
population resides.

33. • NRHM‘s launch in 2005 to the year 2012,
almost 85,368more doctors and Auxiliary
Nurses and Midwives (ANMs) were appointed
to the rural public health
• Additionally, NRHM‘s focus on providing every
village in the country with a trained female
community health activist or ACCREDITED
SOCIAL HEALTH ACTIVIST—building a
workforce of 850,000 ASHAs

34. • Many strategies have been employed, at both
national and state levels, to address HRH
shortages and misdistributions

35. STRATEGIES
• New public health cadres,
• Task shifting
• Strategies for retention in rural areas
• Contracting private health workers (public-
private partnerships)
• Performance-based incentives

36. NEW PUBLIC HEALTH CADRE
• An effective longterm solution to the chronic
shortage of health workers in some specific areas
• Multi-disciplinary professionals for managing
public health
• The licentiate system—preparing a cadre of
nondoctors who can conduct limited professional
practice.(US,canada)
• Nurses are managing antiretroviral therapies
(ART) in primary health centers across Africa

37. BRMS
• Union Ministry of Health and Family Welfare
had proposed a three-and-a-half-year
Bachelor of Rural Medicine and Surgery
degree to exclusively serve the rural
population
• The scheme proposed their training at district
hospitals, which are already ill-equipped,
poorly staffed, and overworked

38. CHATTISGARH MODEL
• In 2001, Chhattisgarh introduced a three-and-
a-half-year Diploma course to produce a
cadre of Rural Medical Assistants
• Closed in 2009, with reasons such as haste in
implementation, lack of support from medical
councils, and absence of a career path for
RMAs
• 1,263 graduates are currently employed under
NRHM

39. • Increasing intake of MBBS graduates
• Compulsory rural posting for MBBS doctors
• Incentivizing service in rural areas

40. TAMILNADU MODEL
• In 1952, TamilNadu made a policy decision not
to amalgamate its medical and public health
services.
• The state has a separate Directorate of Public
Health,
• Assisted by non-medical specialists
• Carefully trained for an administrative and
management role rather than a clinical role.

41. PUBLIC HEALTH COURSES
• Training of in-service health personnel in public
health management
• Post Graduate Diploma in Public Health
Management (PGDPHM) to train health
professionals already working in public health.
• Between 2008 and 2011, 386 students graduated
from the program.
• The Government of Madhya Pradesh pioneered
this approach by nominating nursing staff for
PGDPHM and assuring them suitable placements

42. Task shifting

43. • Involves redistribution of tasks among the
health workforce

44. Empowering Non Physician
Healthcare
• Need to adopt task shifting and non-physician
prescribing.
• Non-physician health care providers would not
only increase availability and accessibility to
health care in rural areas
• Create an empowered second line of health
cadres

45. GUJARAT &RAJASTHAN MODEL
• Federation of Obstetric and Gynaecological
Societies of India and with technical assistance
from the Johns Hopkins Program for International
Education in Gynaecology Obstetrics
• 2006 instituted a 16-week CEmOC training
program Emergency obstetric care
• Training for 18+16 medical officers
• LSCS, Anaesthesia.....
• 134 LSCS by them

46. LSAS—The Gujarat experience
• A 17-week Life-Saving Anesthetic Skills program
to train general Medical
• Gujarat‘s LSAS training program has two parts
• 12 weeks at a medical college learning
anesthesia theory and resuscitation skills
• six weeks in a district hospital for further
practical training.
• Both parts are supervised by experienced
trainers, and resuscitation is emphasized
throughout the training.

47. SAMASTHA -KARANATAKA
• A program in Karnataka, took a slightly different
approach now referred to as the "link worker"
model.
• The Samastha project developed a network of
PLHIV for strengthening and supporting their
adherence to treatment.
• Link workers were PLHIV who were selected by
Samastha from a small number of HIV-positive
candidates proposed by their community; they
received an allowance for their work.

48. Bihar & Jharkhand-Post abortive care
• MVA is still the domain of obstetricians-
gynaecologists and certified physicians, which
severely restricts access to PAC in rural areas
• 10 non-certified physicians and 10 nurses. All
selected providers were given MVA training
for 12 days, followed by a one-week field
placement

49. • The investigators found an insignificant
difference on most indicators, including
patient satisfaction, and no difference on
some.
• The overall failure and complication rates
were low and equivalent between the two
provider types

50. MANAS ( Manashanti
Sudhar Shodh)
• Efficacy of a collaborative stepped-care
intervention
• lay health counsellors in improving outcomes
for people suffering from common mental
disorders

51. Madhya Pradesh‘s Swavalamban
Yojana
• Rural women from underserved districts are
sponsored for nursing courses

52. TRAINED DAIS
• The dai, or traditional birth attendant (TBA),
remains the primary health care provider.
• Typically an older or widowed woman
• Many women in remote areas in India
continue to prefer home deliveries conducted
by a dai

53. Village Health Guides
• A village health guide is a person with an
aptitude for social service.
• Mostly women.
• Links between the community and the
governmental infrastructure.
• First contact between the individual and
health system.

54. Anganwadi worker
• An anganwadi for a population of 1000.
• training in various aspects of health, nutrition,
and child development for 4 months.
• a part‐time worker.
• Beneficiaries

55. ASHA
• Community healthworkers as a part of NRHM
• act as health educators and promoters in their
communities

56. Yashoda
• ‘Yashoda’, a dedicated non-clinical support
worker
• helping motivate mothers to stay for a longer
duration
• assist the nurses with initial care for the
mother and the newborn soon after the
delivery

58. KERALA
• Doctor population ratio is less
• Health indicators are the best in India

59. • Dispensing medicines through subcentres
• Telestroke units in District hospitals
• Daycare chemotherapy centres by MBBS
doctors
• NGO s in CSW Samghamithra project
• Palliative care
• Separate public health cadre

60. Strength
• More access to health for the community
• Acceptabilty
• Can be modified according to local needs
• Cost effective

61. Weakness
• 2 types of health care in country
• Not serve the local needs
• Existing health system weakens sometimes
• Lack of motivation from health workers
• Duplication of resources

62. References
1. Dal Poz MR, Kinfu Y, Dräger S, Kunjumen T, Diallo K. Counting health
workers:
definitions, data, methods and global results. Geneva, World Health
Organization, 2006(background paper for The world health report 2006;
available at: http://www.who.int/hrh/documents/en/).
2. International Labour Organization. International Standard Classification of
Occupations(http://www.ilo.org/public/english/bureau/stat/class/isco.ht
m, accessed 19 January2006).
3. World Health Organization. Global Atlas of the Health Workforce
(http://www.who.int/globalatlas/default.asp, accessed 29 May 2017).
4. Zurn P, Vujicic M, Diallo K, Pantoja A, Dal Poz MR, Adams O. Planning for
humanresources for health: human resources for health and the
projection of health outcomes/outputs. Cahiers de Sociologie et de
Démographie médicales, 2005, 45:107–133.

63. 5.The world health report 2005 – Make every mother and child count. Geneva,
World Health Organization, 2005:200–203.
6. World Health Organization. Burden of Disease
Statistics(http://www.who.int/healthinfo/bod/en/, accessed 19 January
2006).
7.Bhutta et al. 2010
8.World Health Statistics Report (2011)
9.Ministry of Health and Family Welfare. 2006. Report: Task Force on Medical
Education for the National Rural Health Mission.
10.Ministry of Health and Family Welfare, Government of India
11.Rao, Krishna D. 2011. Situation Analysis of the Health Workforce in India.
Human Resources Background Paper 1. Public

64. 12.Health Foundation of India.Available from:
http://uhcindia.org/uploads/RaoKD_SituationAnalysisoftheHealthWorkfor
ceinIndia.pdf
14.Sharma et al. 2013. Economic & Political Weekly, 30 March 2013; XLVIII .
15. Referral for Profit: Deprofessionalization of Health Care in America Dina S.
Macs, Adjunct Professor of Physical Therapy, University of Puget Sound
16.Health at a glance-2014,Directorate of Health services
17.World Health Organization. 2010. Global Policy Recommendations –
Increasing access to health workers in remote and rural areasthrough
improved retention. Geneva: WHO.
18 .Ministry of Health and Family Welfare.2006. Report: Task Force on
Medical Education for the National Rural Health Mission.Ministry of
Health and Family Welfare, Government of India