Rural Medical Assistant Services Innovation
Department of Health & Family Welfare, Government of Chhattisgarh

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In India, the state of Chhattisgarh was carved out of south-eastern Madhya Pradesh (M.P.) in late (November) 2000. With regard to key socio-economic and health indicators (including IMR and MMR), this state lagged behind the rest of the country. The population of 20.83 million (2001 Census) was dispersed with one thirds being tribal, the highest amongst large states and 40% of the land areas is classified as forest lands. Providing health care is a human resource intensive activity, and in Chhattisgarh state the shortage of trained health care providers was among the most acute in the entire country. The state was having 4692 sub health-centers sanctioned and of these almost one-third did not have even a single Auxillary Nurse Midwife ( ANM ) though they were expected to take on two ANMs. Only 540 staff nurses were available against the 1344 required by prevailing National Indian Public Health System norms for working in primary and secondary public health facilities in Chhattisgarh (National Health Systems Resource Centre (NHSRC) and Academy of Nursing Studies, 2009). The shortfall for doctors both MBBS graduates and Specialists was about 72%, with 1455 medical officers posted at PHC against the posts of 1737 and only 247 specialists available against the sanctioned 637 posts (State PIP 2009-10). The shortfall in doctors is even more severely felt as the vast majority of the inadequate numbers that did exist were located in urban or semi-urban areas, with certain large tracts of rural and tribal areas almost devoid of even a single doctor-( with MBBS qualification). In the year 2001 only 516 medical officers were available at PHC level out of total of 1455 sanctioned posts. By 2007 it had increased to 1345 but this was still only about half the number of sanctioned posts. As the numbers of facilities and number of posts rose to meet the national norms, the gaps between what was posted and what was needed become even more. Since the formation of Chhattisgarh, the largest challenge the state government has faced in the health sector is the human resources challenge. Chhattisgarh had one of the lowest human resource densities in India. The World health report 2006: Working together for health recognized the centrality of the health workforce for the effective operation of country’s health systems. Before Independence two classes of allopathic physicians were present in the workforce; doctors who underwent a five and-a-half-year course and Licentiate Medical Practitioners (LMPs) who underwent a three to-four-year course. Nearly two-thirds of the qualified medical practitioners were licentiates who mostly served in rural areas.2,3 In the post-Independence period, the adoption of the Bhore Committee (1946) report and the focus on producing a ‘basic’ doctor for the whole country, saw the abolition, despite much dissent, of the Licentiates. As was the international trend at the time, India was to produce only one type of allopathic physician, the five year MBBS graduate.One consequence of this policy was the acute shortage of qualified clinical care providers in rural India.

B. Strategic Approach

 2. What was the solution?
In order to resolve the shortage of clinical providers, government tried to motivate the clinical providers on the pay roll in many ways to go and serve in rural areas of the state. The State Public Service Commission advertised job vacancies in 2001, 2003-4 and 2005. Less than half of the positions were filled till 2005 and in 2009 even less than 25% of advertised positions were filled. The State tried many measures such as implementing a policy/strategy to retain health staff in rural or remote areas, various financial and non-financial incentive systems, Chhattisgarh Rural Medical Corp-CRMC policy (one such policy/strategy to attract and retain doctors), reservation of Post Graduate seats in the state for doctors serving in rural areas, priority to provide residential quarter (housing), and even compulsory rural posting. All these measures failed to reap results as MBBS doctors had more lucrative options (like private practice and jobs that were inclined to clinical practice especially in urban areas). Today, non-physician clinicians are increasing viewed as a preferable means of delivering primary health services in a cost effective manner. In particular, where physicians are scarce, non-physician clinicians offer an important way to continue services. In several developing countries, particularly in sub-Saharan Africa, the acute shortage of physicians in rural areas has led to non-physician clinicians becoming the main providers of primary health care, and in some instances, specialist services. The few assessments done on the performance of non-physician clinicians have shown them to be as capable as physicians in primary health settings. The initial idea of a 3-year diploma course for training a health care practitioner for rural areas stemmed from the new Chief Minister’s office and was a result of his direct intervention. The initial logic was that if candidates from rural areas are brought into a 3-year diploma programme, they would be more likely to return and serve in such areas. Their opportunities for urban private sector employment would be less. Another rationale that was articulated was that a formally trained skilled provider in the underserved areas of Chhattisgarh would serve as a better than to the “jhola chaap” doctors practicing in these regions. This is a term that derisively refers to the unqualified practitioners of modern medicine that has mushroomed over the villages. Given the fact that the outcomes from new medical colleges would take over six years to be visible, a three year course would yield results within the political lifespan of the government of the time. Moreover, starting new medical colleges, conforming to guidelines of the Medical Council of India (MCI) required significant capital investment from the government and recruitment of human resources. Even if the financial resources were to be found, the human resources would be difficult, for even the existing state college in the state capital was facing shortages of key faculty members. Realizing the need of some innovative and strategic intervention to address the problem the state Government introduced a three year course for rural medical graduates in 2001, producing a new generation of medical graduates, with the idea behind this being that if candidates from rural/ tribal areas were trained to become clinical service providers, they would be more likely to return and serve in the rural areas. Posting of the RMAs was done at all Primary Health Centers ( PHCs) in a phased manner over a period of two years. Now at any given point of time, in any PHC a qualified medical staff is available in the form of Rural Medical Assistant, leading to an increase in outpatient and inpatient registrations and institutional deliveries at PHC’s.

 3. How did the initiative solve the problem and improve people’s lives?
In no more than 200 words, illustrate what makes the initiative unique and how it addressed the problem in new and different ways. List the creative and innovative approaches that allowed for its success? The training curriculum for these Resident Medical Assistants was unique. A modified teaching schedule with more community oriented learning - intrinsic to the curriculum and conditional licensing was established for a set of services and an enabling environment provided to practice primary health care. The course was termed “Practitioner in Modern and Holistic Medicine”. From early 2001, when discussions to the three year course began, opposition from the Medical Council of India, the professional council regulating medical education, was anticipated. In discussions shared among the Health, Law and General Administration Departments of the Government of Chhattisgarh, it was agreed that the powers of recognizing the council which would approve the three year course should be given to a body created for the purpose through an Act passed in the Chhattisgarh state legislative assembly. This was a strategic innovative solution to a complex problem. Unlike for MBBS graduates, the one year of internship for these three year students has a significant exposure to rural public health system with 1 month of training at Sub-Health Centre, 3 months at Primary Health Centre (PHC), 4 months at Community Health Centre (CHC) and 4 months at District Hospital (DH).

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The Chhattisgarh Government knew that the Medical Council of India would not approve a 3 year course for a separate cadre of physicians and thus planned to pass a State Act without requiring the approval of the central/federal government or the President. MCI rejected this course, but the Chhattisgarh government proceeded, using existing precedence of West Bengal having briefly implemented such a course and with the knowledge that in Maharashtra and Karnataka, similar courses had been implemented. Within a month, a committee of senior secretaries presided by the Chief Secretary forwarded a letter of approval to the Chief Minister and in the next month the assembly met and passed the act and the Chhattisgarh Chikitsa Mandal (CCM) came into existence. The teaching institute locations proposed were in rural/tribal districts, but with access to a large government hospital usually the district hospital to make it possible for clinical teaching and internship. Six such colleges came into being and allowed to admit 150 students per year in 3 categories : a) 50 % free merit seats, b) 35% payment merit seats and c) 15% Non Resident Indians seats. Admissions happened for three years before the course was stoppedon 1st September 2008 owing to the Indian Medical Association (IMA), representing largely private doctors, opposed the 3 year course of medical education as a dilution of the standards of the medical profession and other developments such as change in name of the course to “Diploma in Holistic Medicine and Paramedical Course”. The total of 1391 students underwent these courses. A plan was mooted to appoint Rural Medical Assistants in lieu of the second Medical Officer post in which recruitment was kept in abeyance which would also help the government in saving half the salary. Over half of the State’s 700 odd Primary Health Centres were languishing for the lack of a qualified doctor. 303 RMA posts were filled in 2008 and posted in the most remote and difficult areas of Chhattisgarh. In light of this positive experience of posting RMAs in underserved remote areas and existing 740 vacancies of Medical officer, the state has recently increased the total RMA posts to 858. With the policies of contractual appointments of MBBS doctors and recruitment of contractual AYUSH doctors at the post of MOs, only 1407 posts could be filled out of total MO posts of 2147. Therefore to make up the gap, the state government introduced one RMA post at all PHCs and an additional post for Lady RMAs at the higher level Community Health Centre in all the districts of Chhattisgarh irrespective of the difficult, rural or tribal status of the districts. Then next round of inductions resulted in the strength going up to 858 RMAs.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The operationalization of the plan in the Government was given to a committee in the Health Department after which another committee of senior secretaries presided by the Chief Secretary gave approval. The institution formed under the related Act passed by the State Assembly was known as Chhattisgarh Chikitsa Manadl comprised the Director of Health Services as President, the Dean of the Medical College in the state capital as Vice-President and a district chief medical officer to be seconded in as Registrar. There were in all six privately managed teaching institutions which came up in two phases. The first three colleges were inaugurated in October, 2001 at Ambikapur, Jagdalpur and Pendara Road. At this stage, the syllabus for the remaining two years was still not prepared. Three further institutes at Kwardha, Katghora and Kanker opened a year later in end 2002. The unusually rapid progress in setting up these courses, despite legal hurdles related to the strong political will – in the form of the chief minister’s personal and explicit priority for this scheme.
 6. How was the strategy implemented and what resources were mobilized?
Political will led by the personal involvement of the Chief Minister was the most significant contribution. Within the Government, the Departments of Health with support from the Law and Finance Ministries took up the programme through several Committees. The 3-year courses was planned to be managed by private institutions and funded through registration fees charged to graduating three year doctors and private managements of these institutions were expected to recoup these losses and make a profit through tuition fees. The costs to the government of running the CCM were expected to be minimal with a total of only three officials linked to the new registration body; all of whom were already on government payrolls. Two Inspection committees in 2004 and 2005 examined the syllabus and recommended changes in syllabus to make it more appropriate for the epidemiological needs of the rural and tribal population- but these were not carried out. The only modifications made related to alternative and holistic medicines and was done to justify the new names of the course.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Skilled Human Resource gap filled - Around 1391 persons were trained under the 3 year course with a majority of them now serving in remote rural and difficult areas where qualified doctors are not available and rendering health care services to a large section of the state population. RMAs are managing ailments like common cold, fever, diarrhea, Reproductive Tract Infections, Urinary Tract Infections, piles etc.; implementing all the national disease control programs like malaria, filaria, tuberculosis, HIV/AIDS, immunization etc. apart from some of them assiting in the management of Non Communicable Diseases (diabetes, hypertension etc). Minor surgical procedures like stitches for cuts and injuries, incision, drainage of abscesses, management of 10-20 degree burn cases, primary management for stabalizing and referral of emergency cases to appropriate higher centres are also done by RMAs.

 8. What were the most successful outputs and why was the initiative effective?
An impact evaluation of this initiative was carried out in 2009 by the Public Health Foundation of India, New Delhi, the National Health Systems Resource Centre, New Delhi and the State Health Resource Center, Raipur supported by WHO, which further established the role of these rural medical assistants in improving the health services at the PHCs. Based on the findings a letter was issued (Government Order no: F-1-121/2010/17/1 and dated on 03.04.2010) stating that the physician (MBBS doctor) will be posted at the community health centers (CHC) and they will supervise the PHCs run by RMAs. In a study done in 2010 it was seen that there were no significant variation in prescription effectiveness scores and clinical case competence scores of RMAs when compared with Medical Officers

 9. What were the main obstacles encountered and how were they overcome?
The Indian Medical Association (IMA), opposed the 3-year course of medical education as a dilution of the standards of the medical profession. IMA filed a case questioning the legality of the Chhattisgarh three year course almost immediately after the CCM Act. There was very limited clarity on three vital issues- the syllabus, the exact identity of the graduating students, and institutional provisions related to standards and the transparency of process – especially admissions, hiring of faculty and maintenance of quality in certification. At the time of the CCM Act, the 3-year diploma course was to create a “Practitioner in Modern Medicine & Surgery”. Three months later, however, the course was re-titled “Diploma in Alternate Medicine”. The attempt to link the course to the universities delayed the first-year examinations by nearly half-a-year. The name of the 3-year course was changed to “Diploma in Holistic Medicine and Paramedical Course” in March 2003. The students launched an agitation declaring that the term “paramedical” was a dilution of the status of the course. The name of the course instead was revised again following the July 2003 student strike to “Diploma in Modern and Holistic Medicine”. The second major agitation was in July 2004 for change of the name to “Practitioner in Modern and Holistic medicine” and in order to increase the duration of internship from 6 months to one year. This led to the change of the name for the final time and an increased duration of internship to one year. The longest strike lasted one month in December 2006 with the main demands remaining the same, including recognition of the course by State Medical Council in order to practice allopathy.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Significant increase in Out patient Tends after induction of RMAs – OPD attendance increased from 4316954 in 2008 - 2009 to 10368105 in 2013-2014. Since the RMAs are providing basic health services at the lower level of the health system the Medical Officers have been made available in adequate numbers at the above levls such as the Community Health Centres.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The 3-year course was a response to a major crisis in human resources for health that the newly formed state of Chhattisgarh faced. The struggle relating to this issue also led to other efforts in resolving the problem of human resources : One effort was to open up new medical colleges. Two colleges have been successfully opened and two more including a centrally sponsored one is planned. The other was nursing schools and ANMs schools. These two have opened up and though less in numbers and slower to start off than could be asked for they are progressing well. The Mitanin programme, a community health volunteer programme of a woman health activist in every hamlet that is doing relatively well. It has survived and grown and it is exploring new directions of growth. The country has taken up this model and replicated this in oother states through the National Health Mission.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Problems occurred owing to the speed with which initial implementation of the 3-year course for RMAs as it did not allow time for substantial consideration of the various aspects such as curriculum, course name etc. Expansion of medical education is a fundamental political activity which can be brought about speedily only through committed and sustained political will at the senior most level of the Government.

Contact Information

Institution Name:   Department of Health & Family Welfare, Government of Chhattisgarh
Institution Type:   Government Agency  
Contact Person:   Amar Agrawal
Title:   Mr.  
Telephone/ Fax:   917712331020/917712445836
Institution's / Project's Website:  
E-mail:   amaragrawal229@gmail.com  
Address:   C4, Shankar Nagar
Postal Code:   492001
City:   Raipur
State/Province:   Chhattisgarh
Country:  

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