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      Role of AYUSH doctors in rural healthcare: Authors’ responses to critical comments

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      Journal of Ayurveda and Integrative Medicine
      Elsevier BV

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          Abstract

          Dear Editor, We went carefully through the letter written by Prof. S S Savrikar published in J-AIM [1] in response to our article titled “Allopathic, AYUSH and informal medical practitioners in Rural India – a prescription for change” [2]. While thanking him for his comments, we feel a necessity to clarify the more substantive issues raised. 1 Major points of contention Prof. Savrikar, to summarise, primarily argues that well-trained AYUSH practitioners will be a reliable cadre of workforce to cater to the acute illness-related healthcare needs of people living in remote rural villages. To support his view, he writes that the number of AYUSH practitioners working in rural areas as reported by the National Sample Survey Office (NSSO) survey is possibly inaccurate as the sample size of the study was too small [3]. He further goes on to argue that AYUSH practitioners are competent enough to practice Allopathy and to offer their services in rural areas in the public sector. He blames the Government machinery for not giving the AYUSH sector opportunities as deserved. He repeatedly cites (often unsourced) data from the state of Maharashtra to support these arguments. 2 Our clarifications a. Our paper is not Maharashtra-centric and addresses a situation that is prevalent Nation-wide, the magnitude of which has been supported with published data referred in our paper. Hence, it must be noted that many observations that might be relevant to the state of Maharashtra cannot be extrapolated and generalised for the country. b. While rightly pointing to the shortcomings of the NSSO survey, Prof. Savrikar has completely overlooked the massive work of WHO, Geneva, which was cited by us and provides many decisive insights on the issue of India's healthcare workforce by de-coding data derived from the Census of India [4]. The magnitude and role that unqualified medical practitioners (UMPs) play in rural health care has been recounted based on irrefutable data which shows conclusively that neither modern medicine doctors nor AYUSH doctors -whether they practice in the public or private sector -are available to provide treatment for acute illness episodes. The distance and several other deterrents has made the unqualified practitioner, the first port of call. c. Prof. Savrikar has chosen to ignore the report on UMPs authored by the first author of this communication wherein the current situation that compels village households to depend overwhelmingly on UMPs has been elucidated with referenced data [5]. In our paper, we have explained the reason for this state of affairs with supporting evidence. In such a situation, advocacy that AYUSH doctors be given drugs and support to practice allopathy is unrealistic. Innumerable efforts have been made to fill the gaps in the quantitative and qualitative shortcomings in the rural health infrastructure consisting of Sub-Centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs). There is no dispute that those efforts must continue but the question of improving access to medical treatment for assorted medical conditions at the community level (India has 600,000 villages where the bulk of the rural population lives) remains unanswered. We have cited various factors such as rampant employee absenteeism, long travelling distances, unreliable drug supply, shortage of staff and bad roads, as well as a quantitative shortage of these facilities that discourage people from accessing help from rural public health facilities. d. There is a Nation-wide survey on the clinical skills and competencies of Ayurveda students published by the second author of this communication which has inter alia revealed the inadequacy of exposure to a cross-section of medical conditions which is needed to acquire clinical proficiency among graduates [6]. The presumption that ‘Appropriately trained’ AYUSH doctors would serve as a better option than medically trained auxiliaries – is unrealistic - an argument continuously posed by us. The paucity of ‘appropriately trained’ and ‘well learned’ AYUSH doctors has been referenced in our paper. Even when they are available they gravitate to urban areas because of better opportunities and remuneration. 3 Inattentive remarks Prof. Savrikar has unfortunately made some inattentive remarks without going through our original paper. Following are a few examples: a. Our paper does not mention that contractual AYUSH doctors refuse to work in remotely located PHCs. The statement in our paper was in the context of Allopathic doctors, not AYUSH doctors. b. The author states that a well-learned AYUSH doctor can treat Non-Communicable Diseases (NCDs) successfully. He further argues that no special skills or competencies are required to prevent or treat NCDs. If this were indeed true, serious, chronic conditions such as diabetes, hypertension, obesity, depression etc. should not have become the burgeoning challenges of contemporary society. Further, there would have been many good studies showing the evidence that AYUSH systems work well in treating these conditions, which is not the case. We, in our paper, have suggested that if AYUSH systems are to be put to their maximal use their role in NCDs should be explored. c. His reactions to consider the possibility of introducing a separate entrance examination for AYUSH programs are not backed by any data. Supporting sourced evidence on when and in how many institutions such a strategy was attempted and went awry and the foundation for saying so have not been given. d. Our proposal for establishing a cadre of licenced, medically trained, and registered auxiliaries working under GPS manned supervision is aimed at filling the huge gaps that exist at the tehsil and village level that are presently filled overwhelmingly by UMPs. We do not understand how the author has converted this suggestion to allude to induction of ‘half-trained UMPs’. Sources of funding Not declared. Conflict of interest None.

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          The Ayurveda Education in India: How Well Are the Graduates Exposed to Basic Clinical Skills?

          “Ayurveda” is an ancient system of healthcare that is native to India. At present, in India, there are more than 240 colleges that offer a graduate-level degree (Bachelor of Ayurvedic Medicine and Surgery—BAMS) in Ayurveda. Even though the Central Council of Indian Medicine, the governing body that monitors the matters related to Ayurveda education, has imposed various educational norms and regulations, the standard of education has been a cause of concern in recent years. The mushrooming of substandard Ayurvedic colleges is the most important factor that is being held responsible for this kind of erosion in the standards. The present study is a mailed survey, which was carried out to evaluate the “Extent of exposure to basic clinical skills during BAMS course” as perceived by the sample groups of students and teachers drawn from 32 Ayurvedic educational institutions spread all over India. A methodically validated questionnaire was used as the tool in the study, to which 1022 participants responded. The study indicates that there are some serious flaws in the existing system of the graduate-level Ayurveda education. Since the Ayurvedic graduates play an important role in the primary healthcare delivery system of the country, governing bodies are required to take necessary steps to ensure the adequate exposure of the students to basic clinical skills. Along with the strict implementation of all the regulatory norms during the process of recognition of the colleges, introducing some changes in the policy model may also be required to tackle the situation.
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            • Record: found
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            Allopathic, AYUSH and informal medical practitioners in rural India – a prescription for change

            This paper looks at the treatment seeking behaviour of rural households and presents factors that discourage them from using public health facilities. It also brings out how Allopathic medical graduates as well as institutionally qualified AYUSH doctors predominantly offer services in cities and townships which results in lakhs of village households having to depend on unqualified medical practitioners as the first line of medical treatment; also how this situation will continue unless the approach to providing medical treatment is modified. Continued dependence on unqualified practitioners is fraught with dangers of incorrect diagnosis, irrational drug use, resulting in the spread of multi-drug resistance. The reality that surrounds Allopathic practice by AYUSH doctors has also been described along with the educational underpinnings of accepting this approach. We opine that existing state policies that legitimise Allopathic practice by non-Allopathic practitioners do not help the rural poor to access proper medical treatment for acute conditions. Also, it does not enhance the credibility of the indigenous systems of medicine among which Ayurveda is the dominant system. First, we position our views in the context of the recently introduced National Medical Commission (NMC) Bill 2017 and provisions which call for the assessment of the need for human resources for health and building a road map to achieve the same. Second, we advocate re-inventing the pre-independence system of trained medical auxiliaries enrolled on a new schedule of the respective state medical register, authorised to give immediate medical treatment and making informed referrals for further diagnosis or specialised treatment. Finally, we recommend reinforcing the AYUSH systems to tackle emerging non-communicable diseases which are affecting all population cohorts adversely and, in whose prevention and management, the AYUSH systems are reported to possess special skills and competence.
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              Composition and distribution of the health workforce in India: estimates based on data from the national sample survey. WHO South east Asia

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                Author and article information

                Journal
                Journal of Ayurveda and Integrative Medicine
                Journal of Ayurveda and Integrative Medicine
                Elsevier BV
                09759476
                May 2019
                May 2019
                Article
                10.1016/j.jaim.2019.04.001
                a83f9f37-17f8-4a17-848c-196be027d4c9
                © 2019

                https://www.elsevier.com/tdm/userlicense/1.0/

                http://creativecommons.org/licenses/by-nc-nd/4.0/

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