On 21 September this year, the Odisha Health and Family Welfare department issued a notification allowing pharmacists to treat minor ailments and dispense drugs for certain diseases at Primary Health Centres (PHCs) in the state that are managed by a single doctor or without a doctor. The minor ailments included malaria, fever, skin diseases (scabies and ringworm), diarrhoea, minor injuries without medicolegal cases, and a few others. For directly communicable (DC) and non-communicable diseases, pharmacists have been permitted to dispense previously prescribed drugs or any medicines prescribed by tele-medicine.
The notification mentioned that this will help address the problem of some hospitals being managed without doctors. "It is difficult to manage the said hospitals without any specific government orders entrusting pharmacists for treatment of patients and list of ailments to be treated by them." it said. The shortage of doctors in PHCs had a disproportionate effect during the pandemic; several PHCs in the state were already being managed only by pharmacists when the virus struck, but were not authorised to provide much treatment.
According to the Rural Health Statistics 2019-20 report released in April, Odisha has the highest shortfall of doctors in PHCs. Every PHC is supposed to cater to a population range of 20-30,000. However, based on the mid-year population as on 1 July 2020, the report found that India's PHCs cater to an average of 35,730 people. That is already very far from the WHO recommended doctor-to-population ratio of 1:1000. The number of PHCs in Odisha has also seen a meagre increase from 1282 to 1288 between 2005 and 2020. These numbers are insufficient for a population of 4.20 crore, as per the 2011 Census data.
Commenting on this order, Dr Bijoy Mohapatra, the Director of Health Services, said it would address the acute shortage of doctors in rural PHCs. "In 2003 under the Panchavyadhi scheme for treatment of five illnesses - fever, dysentery, vomiting, headache and stomach pain - we trained the pharmacists to dispense medicines in the absence of doctors. We just modified the order so that people in rural areas can get treatment," he added.
But can they do the job?
However, Gouranga Mohapatra, Convenor of the National Jan Swasthya Abhiyan is concerned about this step. "Pharmacists have had no training in basic anatomy or symptoms and treatment of diseases like doctors have," he said. "Without that training, how can they be entrusted to treat the rural population who already face the brunt of our abysmal healthcare systems?" He is not oblivious to the shortage of doctors, but pointed out that this shortage in rural areas was supposed to be addressed by mandatory posting of doctors for a few years. "Earlier, MBBS doctors in Odisha had to serve 5 years in a rural area. That has now been reduced to just one year. That rule is also not strictly adhered to in all cases," he said.
He believes the solution lies elsewhere - investing in proper short-term training instead of such stopgap measures which might backfire dangerously. He cited the example of a 3-year diploma course for training health care practitioners for rural areas in Chhattisgarh - a Diploma in Modern and Holistic Medicine. The course was initiated by the government of that state to address the shortage of doctors as well as their reluctance to work in Naxal rural regions of the state. "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."
Despite repeated opposition from the Medical Council of India and the Indian Medical Association on grounds such as dilution of the standards of the medical profession, the Chhattisgarh government continued with the course for a while. The first batch passed out in 2006 and around 1300 Registered Medical Assistants (RMAs) joined the rural healthcare systems.
In Improving Retention of Health Workers in Rural and Remote Areas: Case Studies from the WHO South-East Asia Region, a case study of this measure, it was reported that the intervention resulted in an increase in availability of MBBS doctors by 207 per cent, specialists by 1300 per cent, and nurses by 1240 per cent from 2009 to 2018. The uptake of health services like out-patient visits and in-patient attendance increased by 243 per cent.
Raman*, a trainee from from this diploma programme in Chhattisgarh does not share Mohapatra's concerns about this order in Odisha. "It is true that pharmacists do not have specialised training, but the order only allows them to dispense medicines for minor ailments for which standard protocols and medications are already in place. In case of DCs and non-communicable diseases, they have been asked to rely on tele-medicine, which means technically only doctors will be able to diagnose and prescribe," he said. He sees the order as a potential 'life-saver' for people. "It is like pharmacists have now been given the same authority as an Auxiliary Nurse and Midwife (ANM) in some sense. That could just help accessibility and affordability of timely healthcare interventions," he said.
More safeguards needed
Gouranga Mohapatra is also worried about accountability. "Just a list is not enough. Where is the ethical practice protocol? How does one go about demanding accountability, when we have already seen how difficult it is in the case of even doctors?" he asked. While the order explicitly states that pharmacists can dispense medicines only from Niramaya - a free medicines distribution scheme of the state government - Mohapatra has his doubts. "Look how there are orders stating doctors must prescribe only the generic name of medicines, but most doctors do not follow this. When doctors are not writing out Niramaya medicines, who will ensure for pharmacists now?"
Regulation, monitoring, and grievance redressal ought to have been dealt with in the order itself, he believes. Raman also cautiously suggested that pharmacists should be given the same training as ANMs before they start dispensing medicines. Like ANMs, pharmacists must also be made to refer patients to doctors and healthcare centres for complications beyond their scope.
The lack of adequate legal safeguards is something which has caught the eyes of the Odisha Pharmacy Intellectual Forum (OPIF) as well. In a statement expressing 'pride' in the government's decision, the coordinator of the OPIF also said, "Since there were instances in the past of legal action taken against pharmacists under medical negligence act, we are apprehensive of the consequences of this decision although it is for the sake of healthcare and medical care." He also said there should be a rule for not invoking provisions of the medical negligence act against the pharmacists for any mistakes or negligence on their part while managing the cases because they are not skilled medical professionals to manage health conditions or treat patients.
Picture: Dang Bahal Public Health Centre
Pattanagarh block, Balangir.
For NJSA's Mohapatra, another possible solution to the shortage of healthcare personnel in rural Odisha could be training AYUSH doctors and dentists who are currently without a job. These people are better trained in basic anatomy and medicines, unlike pharmacists, he said. Raman, however, was not in agreement, citing two reasons. One, from a cost-analysis perspective, training and utilising skills of pharmacists would be more beneficial. Two, there is a need for stock-taking of unemployment as well as postings of doctors. It is the second point that really drives into the heart of the problem - the shortage of healthcare personnel is not simply about there not being enough of them, but about disproportionate urban-rural distribution of them.
The consensus among public health activists is that encouraging healthcare personnels to actually work in rural areas, investing in rural healthcare systems, training and employment of interested persons belonging to each district, and affirmative social justice policies for the same are far more effective solutions. The current order, despite its reasonable intent, is only a piecemeal measure with inadequate data, and without a legal framework. Those could eventually undermine the goal.