Which doctors for primary health care?An assessment of task shifting among primary care clinicians -Krishna D .Rao

Which Doctor for Primary Health Care?Two studies from Chhattisgarh, India

Public Health Foundation of IndiaNational Health Systems Resource Center

State Health Systems Resource Center, Chhattisgarh

Sponsors: AHSPR WHO, NHSRC, SHRC Chhattisgarh

December 10, 2010

Where are the health workers?

3.28 13.34

4.13 15.88

1.04 3.64

0.06 0.59

1.33 4.28

0.66 3.37

0.28 0.92

10.78 42.03

0 20 40 60 80 100Percentage

All

Other Traditional

Others

Pharmacist

Dentist

AYUSH

Nurse & Midwife

Allopathic Physician

Note: Numbers on the Bars Indicate Density (Per 10,000 Population)

Rural Urban

Source: Census of India 2001

Rural-Urban Distribution of Health Workers in India

State Experiments

Many experiments taking place at the state level on strategies to recruit and retain health workers in underserved areas:

• Compulsory rural service • Education incentives (e.g. Post-graduate seats for in-service candidates)• Monetary compensation• Contracting-in doctors and other health workers (most states)• Workforce management (e.g. direct recruitment by ministry)• Non-physician clinicians in primary care

• Allopathic clinicians with shorter duration of training (Chhattisgarh and Assam)• AYUSH doctors (almost all states)

Chhattisgarh State

PHC Clinical Providers in Chhattisgarh

Study 1 - Objectives and Design

• ‘Natural experiment’ allows comparative performance of different types of PHC clinicians on:

• Ability to manage common illnesses (‘how much they know’) i.e. competence• How patients and communities perceive them• The use of the local PHC by ill community members

• Study design:• 40 PHCs in each of four groups randomly sampled• Convenience sample of 10 patients per PHC• Random sample of 15 households in PHC village

Study 1 - Methods: Measuring Competence

• Clinical vignettes used to measure ‘How much clinicians know’ i.e. their competence to manage six standardized cases:

• Malaria in an adult female • Diarrhea in and infant• Pneumonia in a girl child• Pregnancy induced hypertension in a young woman• TB in a middle aged man• Diabetes in a middle aged man

• Cases selected based on the disease profile of Chhattisgarh, conditions commonly seen at PHCs and health priorities of the state.

Study 1 - Results : Clinician Competence Score by Case

02

04

06

08

01

00

Com

pete

nce s

core

Malaria Diarrhea Pneumonia TB Preeclampsia Diabetes All

Figure 6.1 Competence Scores By Case

Medical Officer AYUSH Medical Officer RMA Paramedical

Study 1 - Results: Community Perceptions

Note: Figures are %(N) or Mean (SD); *significantly different from Medical Officer at alpha = 0.05. Standard errors adjusted for clustering of observations.

 Medical Officer

AYUSH Medical Officer RMA Paramedical

Patient satisfaction (%) 84% (266 ) 80% (296) 85% (272) 73% (243)*

Community perception of local PHC (standardized scores):

Able to treat common illness 0.11 0.22 0.01 -0.35*

(-1.015) (-0.852) (-0.903) (-1.122)

Able to treat serious illness 0.4 -0.02* -0.11* -0.28*

(-1.105) (-1.002) (-0.879) (-0.878)

N (households) 512 492 539 502

Study 1 - Results: Health Care Providers Visited for Treatment

Study 2 - Why some health workers remain in rural areas?

• Authors: Sheikh and others (2009) • Method: 37 in-depth interviews conducted with clinical care providers in PHC (14)/CHC (13) in eight districts of Chhattisgarh, between June and August 2009.

• Sample: Providers serving in PHC/CHC in a rural (remote) area for more than five (one) years.

Study 2 - Why some health workers remain in rural areas?

• Reasons for serving in rural areas:

• Serving in their own communities / Closeness to family• Post-graduation opportunities• Rural upbringing (most respondents from rural background)• Good schools (for children) in area• Personal values of service• Professional interest in work• Opportunity for both spouses to work (women doctors)• Strong relationship with colleagues & community

Conclusions: What Lessons for Primary Health Care

(1) No need to focus only on allopathic doctors for primary care• Non-physician clinicians (e.g. RMAs) appear competent

o Not claiming they are equivalent to medical doctors• AYUSH doctors, nurse-practitioners also viable but need

focused (protocol based?) training

(2) Provider characteristics (e.g. background, ties to community, interest in being a rural doctor) are important considerations for better retention• Posting clinicians at PHCs for short duration (e.g. through

compulsion or PG reservation) may not best practice

(3) Placing qualified clinicians at PHCs does not automatically create ‘successful’ primary health care.

Thank You

PHCs in Chhattisgarh

Study 1 - Sample

District PHCsRegularMedical Officer

Contract Medical Officer

AYUSH Medical Officer

RMA Paramed Oth

Total PHCs 706 210 123 169 63 53 88

Sampling frame 456 205   135 63 53  

PHC (target) 146 (160) 35 (40)   37 (40) 35 (40) 39 (40)  

Patients (target) 1600 (1,082) 400 (269)   400 (296) 400 (273) 400 (244)  

Hhold (target) 2400 (2,124) 600 (525)   600 (503) 600 (571) 600 (525)  

Health Workers and Health

Goa

UP

Bihar

Kerala

Delhi

Tamil Nadu

20

40

60

80

10

05 10 15 20 25 30

Health Worker Density( per 10,000 pop)

Att

end

ed D

eliv

erie

s(%

)

Source: Census (2001), NFHS-3 2005/06

Attended Deliveries

Goa

UP

Bihar

Kerala

Delhi

20

40

60

80

5 10 15 20 25 30 Health Worker Density( per 10,000 pop)

Infa

nt M

orta

lity

Rat

e

Source: Census (2001), NFHS-3 2005/06

Infant Mortality

Significant Public Sector Rural Vacancies

• Latest government estimates (based on vacancies in sanctioned posts) indicate that: – 18% of the PHCs were without a doctor– 38% were without a lab technician– 16% lacked a pharmacist

• Specialist allopathic doctors are particularly in short supply – 52% of the sanctioned posts of specialists at CHCs vacant. – 55% of surgeon– 48% of obstetrician and gynecologist– 55% of physician– 47% of pediatrician posts

• Nurse vacancies are also high – 18% of the posts for staff nurses/nurse-midwives at PHCs and CHCs are vacant.

Study 1 - Results : Percentage of Correct Responses and Overall Competence

Note: Figures are % (number of relevant items) or mean (SD); * Significantly different from Medical Officer at alpha=0.05.

Medical Officer

AYUSH Medical Officer RMA Paramedical

History 44% (2170) 32%*(2294) 43% (2418) 25%*(2170)Examinations 42% (1365) 29%*(1443) 40% (1521) 21%*(1365)Investigation 81% (105) 75% (111) 80% (117) 61%*(105)Diagnosis 86% (210) 66%* (222) 86% (234) 54%*(210)Prescriptions (effective) 61% (140) 51% (148) 61% (156) 33%*(140)Home care 37% (1155) 31%* (1221) 37% (1287) 26%*(1155)

Competence score (range 0 to 100) 56.5 (8.42) 43.7 (8.36) 55.8 (9.10) 33.8 (9.43)Competence score (std & adjusted) 0.51 (0.47) -0.46* (0.20) 0.44 (0.22) -1.24* (0.19)Number of providers 35 37 39 35