A Rainbow Primary Care

for India

A Concept Paper Dr Shyam Ashtekar

In 1940!

The Pre-Independence Effort

In 1940!

A legacy

Keywords

• Pluralistic Primary care,

• AYUSH,

• Draft NHP2015,

• National Health Assurance Mission, • National Health Assurance Mission,

• Flexi-learning,

• Health Centers,

• Legalities

A window of opportunity for new

primary care

• NHP 2015 and NHAM provide a free and

comprehensive primary care for all

• Intention of including AYUSH along with

AllopathyAllopathy

• Intention of taking primary care deeper in

public health system, and in private care

• Renewed commitment to B.Sc Health Science

• A separate ministry of AYUSH

The Large Ground Realities

Quacks galore in Purniya Bihar 2013

The ubiquitous Zolachhap doc in UP 2013

The varying contexts of primary care in India.

• States vary widely in doc density.

• This changes the primary care scenario in various states

• South, western and Delhi • South, western and Delhi Punjab JK have higher doc density and may be difficult for a new primary care

• But many other states need and can benefit from new primary care,

The assets-HR and institutes

A Lakh of health subcenters

100000 Health subcenters

A million ASHAs

To rebuild new primary care..

• HR--AYUSH doctors, ASHAs, paramedics, informal doctors

• Institutes-health subcenters, village panchayats equipped with 72ndpanchayats equipped with 72amendment.

• NHAM, CSR (Corporate Social Responsibility) and AYUSH funds

• New courses and bridge courses for primary care

Need for AYUSH in mainstream

primary care

• Despite limited and disputed evidence of efficacy, the current Allopathy practice is driven by its industry and market network

• The four solid reasons for integration are (a) internal medical value of AYUSH (b) Wide internal medical value of AYUSH (b) Wide resource base in terms of HR and material (c) Cost advantages (d) an alternative pathway for our health system.

• AYUSH is one way of avoiding the rising hegemony of Modern Medicine over the national health system.

A Pluralist Primary care

Allopathy Ayurveda Homeopathy Siddha Yunani Yoga Acu Naturopathy

Academic Framework for new primary care

• We need an Omnibus GP or primary care program, preferably registered with a separate board that will allow a pluralistic care. But this is a long term solution.

• Two levels of training programs are necessary—(a) paramedics/nurses and (b) GPs/basic doctors. At Subcenter level we will need new paramedics with essential skills in primary care.primary care.

• Along with basics of various healing systems, a problem based approach, with an epidemiological/regional selection of 50-100 problems is helpful for specifics. (like for instance what are the various options/approaches for common cold or back pain)

• (Ref Manual-My book on primary care: Health & Healing (Orient Longman 2000) now out of print.)

Institutes and methods

• We will need genuine institutes and integrated hospitals for training in new primary care.

• Customized Academic programs are necessary combining (a) face to face conventional combining (a) face to face conventional education with (b) distance learning components for practicing professionals.

• A system of credit points will be suitable for Continuous Medical Education (CME) and distance learning programs.

Using IT platforms

• Using IT platforms for all the learning

material, CME, tests and updating will help us

build curricula in short span of time (say even

one year) and even launch programs as we one year) and even launch programs as we

develop such material.

Research and Development for new Primary care

• Modern medicine has banked too much on clinico- pathological diagnosis

• But ISM and Homeopathy have different approaches.

• We need more brainstorming and EBM (Evidence • We need more brainstorming and EBM (Evidence Based Medicine) to develop guidelines for an integrated primary care.

• These guidelines will be used in a public/Government system across states and hence need to be legally defensible.

Beyond RCTs

• In the long run, we will need a body of EBM on integrated primary care, and for that we may need more research models than just the RCTs (Randomized Control Trials).

• There are academic and research methodology • There are academic and research methodology issues about testing and proving holistic approaches versus the reductionist approaches of Allopathy.

• This subject needs a closer look for working out solutions within the larger framework of inter pathy research and AYUSH mission.

Legal issues of integration for new primary care

• To start with, all three councils –Modern Medicine or Allopathy, Indian Medicine, Homeopathy are separate entities.

• In ISM, Ayurveda, Sidha and Yunani have separate registries.

• Naturopathy and Yoga are not recognized as healing • Naturopathy and Yoga are not recognized as healing systems for separate registration.

• Essentially, any academic program has to have a mandate from the respective council, list of institutes offering an approved course like this one, and individual registration with respective state council for the said practice of that science/healing system.

One law for ‘two

countries’

• We are straddling ‘two countries’--

India and Bharat with one MCI

act. While regulation looks right in

India (cities & towns mainly), it

renders most of Bharat’s doctors renders most of Bharat’s doctors

and practice illegal.

• We need accomodative/ promtive

legal provisions for rural areas.

Legal Options

• The Parliament will have to revisit the council acts, find a solution to successful integration of AAYUSH at the level of primary care.

• One way is to merge the various councils and make a single HHR (Health Human Resources) council

• Another way, for the short term, is to get the MCI to • Another way, for the short term, is to get the MCI to run 1-2 year bridge courses for other graduates allowing limited list of remedies (say 30-50), get appropriate separate registration for them with state councils.

• We can have a shortcut by decontrolling some 30-50 essential primary generic medicines on the counter

Need--A new Board for primary care

• For primary care/integrated GP, we may finally

need a new Board that can run such

courses, register practitioners and function

like a state council mandated by the three like a state council mandated by the three

central councils.

A Roadmap to AAYUSH Primary Care

Area Short term measures Long term measures Remarks

1 Legal issues Need to free some 30-50

allopathic medicines for

popular use, with adequate

information in local languages

Parliamentary legal remedy to

pool various councils, launch a

AAYUSH Graduate program

Calls for advocacy and take

IMA along.

2 Academic Prepare a syllabus for AAYUSH

level 1 (1 yr bridge for

practicing) & level 2 (4Y) for

Integrated and EBM research

through academic and service

institutes

Need to work out

integrated protocols,

research protocols and practicing) & level 2 (4Y) for

fresh students programs

institutes research protocols and

approval mechanisms

3 Infrastructure Start AYUSH OPDs at

Subcenters with help of part

time AYUSH doctors

Integrated AAYUSH hospitals

for learning centers

Need to review the

National AYUSH Mission &

NHAM policy

4 Finance The AYUSH mission has

provisions for health system

institutes

Need to popularize AAYUSH

through NHAM, non-profit

and private providers, so that

it gets its shares in private

spending.

It is necessary that AYUSH

not be equated with Govt

facilities alone.

Conclusion

• Primary care is an essential foundation for building any national

health system.

• However we need to rework the existing systems.

• An integrated AAYUSH based primary care is essential to the

health of the people and to that of the larger health system.

• We need to build the academic system support for this, find • We need to build the academic system support for this, find

legal remedies at central /state levels and decide strategies in

various states to work in both public and private sector.

• AYUSH has been waiting to join the mainstream for long,.

• A political solution is necessary to break the impasse between

systems. May be the Parliament takes a call.

• Such an integrated effort will be a lasting national asset.

Our Hindi

website for

primary care

Thanks

Dr Shyam Ashtekar

shyamashtekar@yahoo.com

Website: bharatswasthya.net &

arogyavidya.net

Nashik, Maharashtra, Cell

09422271544