Role of AYUSH workforce, therapeutics, and principles in health care delivery with special reference to National Rural Health Mission.

Decades back AYUSH systems of medicine were limited to their own field with few exceptions in some states as health in India is a state issue. This took a reverse turn after the initiation of National Rural Health Mission (NRHM) in 2005 which brought the concept of "Mainstreaming of AYUSH and Revitalization of Local Health Traditions" utilizing the untapped AYUSH workforces, therapeutics and principles for the management of community health problems. As on 31/03/2012 AYUSH facilities were co-located in 468 District Hospitals, 2483 Community Health Centers and 8520 Primary Health Centers in the country. Several therapeutics are currently in use and few drugs have been included in the ASHA drug kit to treat common ailments in the community. At the same time Government of India has recognized few principles and therapeutics of Ayurveda as modalities of intervention to some of the community health problems. These include Ksharasutra (medicine coated thread) therapy for ano-rectal surgeries and Rasayana Chikitsa (rejuvenative therapy) for senile degenerative disorders etc. Similarly respective principles and therapeutics can also be utilized from other systems of AYUSH such as Yoga and Naturopathy, Unani, Siddha and Homoeopathy. Akin to Ayurveda these principles and therapeutics can also help in managing community health problems if appropriately implemented. This paper is a review on the role of AYUSH, as a system, in the delivery of health care in India with special reference to National Rural Health Mission.

Introduction

AYUSH is an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy and are the six Indian systems of medicine prevalent and practiced in India and some of the neighboring Asian countries with very few exceptions in some of the developed countries. A department called the department of Indian system of medicine was created in March 1995[12] and renamed to AYUSH in November 2003[3] with a focus to provide increased attention for the development of these systems. This was felt in order to give increased attention to these systems in the presence of a strong counterpart in the form of allopathic system of medicine which lead to an “architectural correction” in the health service envisaged by National Rural Health Mission (NRHM). Before the initiation of NRHM most of these systems including workforces, therapeutics and principles were limited to their own field with few exceptions in some states, as health in India is a state issue. This took a reverse turn after the initiation of NRHM and the AYUSH systems were brought into the mainstream health care. NRHM came into play in 2005 but implemented at ground level in 2006 and introduced the concept of “mainstreaming of AYUSH and revitalization of local health traditions” to strengthen public health services.[45] This concept helped in utilizing the untapped AYUSH workforce, therapeutics and the principles for the management of community health problems at different levels. This convergence has been envisaged with the following objectives:

Choice of the treatment system to the patients

Strengthen facility functionally

Strengthen implementation of national health programs.[345]

In the mainstreaming of AYUSH and revitalization of local health traditions AYUSH workforce, therapeutics and principles have been implemented in various states at a different level.

Objective

The main objective of this study was to assess the role and contributions of AYUSH systems including workforce, therapeutics and principles in health care delivery with special reference to NRHM.

Methodology

A review based study. Information pertaining to this study was primarily obtained from various governmental documents in the concerned domain.

Discussion

This section delineates the role of AYUSH workforce, therapeutics and principles. As the paper focuses on the role of AYUSH system with special reference to NRHM, hence a discussion on mainstreaming of AYUSH and revitalization of local health traditions is very much imperative. The concept of mainstreaming of AYUSH was an idea in the 9th five year plan before it was actually implemented in the country by NRHM in 2005.[3] By this AYUSH doctors are co-located in various health facilities such as Primary Health Center (PHC), Community Health Center (CHC), sub district hospital, and district hospital (DH). AYUSH facilities have been created in 468 DHs, 2483 CHCs and 8520 PHCs as on 31/03/2012. About 76.3% DHs, 51.6% CHCs and 35.7% PHCs have been co-located with AYUSH facilities by this time. As on 31/03/2012 there were 1,0439 AYUSH doctors and 4146 paramedical staffs serving in India. A maximum of 1386 doctors have been appointed in the state of Bihar, whereas Orissa and Rajasthan have 1237 and 1013 AYUSH doctors appointed respectively. Delhi and Jharkhand are the only two states where AYUSH doctors have not been appointed. In case of paramedical staffs, Andhra Pradesh is the state where a maximum of 1500 number of AYUSH paramedical staffs have been appointed. AYUSH paramedical staffs have not been appointed in many states like Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Delhi, Gujarat, Jharkhand, Meghalaya, Mizoram, Nagaland, Orissa, Uttar Pradesh, Dadra-Nagar Haveli and Diu-Daman [Figures 1 and 2].[1] Similarly about 17.7 lakhs of rural population were being served by each DHs, 3.3 lakhs of the rural population were being served by each CHCs and 1.0 lakhs of the rural population were being served by each PHCs in various states/UTs wherever the corresponding facilities existed [Tables 1 and 2].[1] The required number of AYUSH workforces has been articulated in the Indian Public Health Standards (IPHS) documents [Table 3].[6789] The role and responsibilities of AYUSH doctors have been spelt out very carefully in their term of reference (TOR). As per the TOR, an AYUSH doctor should support in the implementation of national health programs after requisite training if required. Training and orientation of AYUSH doctor is one of the important agenda of NRHM. There are some job responsibilities mentioned under the TOR which are beyond the scope of an AYUSH doctor as per his/her educational training and exposure. Let us pick up some responsibilities mentioned in the TOR of AYUSH doctors in Orissa; conducting minor surgery, abscess surgery, conducting normal delivery and insertion of intrauterine contraceptive devices are beyond the scope of an AYUSH doctor as per their training and exposure. Similarly planning and implementation of national disease control program, national health programs such as immunization program, Reproductive and Child Health program, supervision of Village Health Nutrition Day and Pustikar Divas, implementation of Integrated Management of Neonatal and Childhood Illnesses requires a lot of training and orientation of AYUSH doctors.[10]

Figure 1

State wise distribution of AYUSH doctors appointed on a contractual basis in primary health centers under National Rural Health Mission till 31/03/2012

Figure 2

State wise distribution of AYUSH paramedics appointed on a contractual basis in primary health centers under National Rural Health Mission till 31/03/2012

Table 1

Average rural population served per Rural Health Infrastructure as on 31.03.2012

Table 2

National level contractual appointments under AYUSH as on 31.03.2012

Table 3

AYUSH workforce as per IPHS guidelines

AYUSH principles have also been utilized for the management of common community health problems. These are evident from the program implementation and planning (PIPs) of various states. Many of such programs are being run successfully in some states whereas some states have asked for approval of some other programs in their PIPs. List of such activities are as follows:

Information Education and Communication (IEC)/Behavior Change Communication (BCC) - The PIP of different states/union territories mention that they held various IEC/BCC activities to sensitize the community regarding the benefit of AYUSH and Local Health Traditions services

Specialty Clinics/Wards - Ksharasutra clinic for anorectal disorders and Panchakarma therapy unit for intensive and specialized treatment have been mentioned by half of the sates in their PIP

AYUSH health programs - School Yoga program and Yoga camp are some of the AYUSH health programs mentioned by states like Orissa, Punjab and Andhra Pradesh. Tripura being little ahead mentions about sensitization of primary school teachers of the importance of Yoga. Rajasthan mentions about “Suposhanam” a community nutrition program for tribal women and Ayurved mobile units

Outreach activities - Jharkhand, Himachal Pradesh, Jammu-Kashmir and Orissa mentioned about utilization of AYUSH doctors in mobile medical units. Madhya Pradesh and Tripura mentioned an innovative program of AYUSH call center in their PIP

Establishment of AYUSH epidemic cell – Tamil Nadu and Kerala are using AYUSH services for prevention and control of epidemics, e.g. use of Homoeopathy for controlling Chikungunya outbreak. Rapid action epidemic cell of homoeopathy is a major AYUSH initiative highlighted in Kerala PIP

Local health traditions - The IPHS prescribes setting up of a herbal garden in sub center and PHC premise within the available space, which has not been reflected in any of the state PIPs. Whereas certain states have mentioned some innovative activities like Chhattisgarh has mentioned about an innovative activity called “Ayurved Gram”, “Dadi Maa Ki Batua” in Jammu and Kashmir PIP which plans to include home reme’dies in AYUSH drug kit. Madhya Pradesh has mentioned about “Gyan Ki Potli,” which also includes available and use home remedies that are accessible and affordable for various ailments. Haryana has planned courses on local health traditions for unemployed youth.[111213]

Several therapeutics have been proposed and many are being used for the management of common community health problems. Some of the drugs have been included in ASHA kit for the management of health problems at the first hand at village level. One of the Ayurvedic products known as Punarnavadi Mandura has been included in the ASHA kit for the management of anemia at the community level. The potential of Ayurveda drugs to tackle community health problems resulting from nutritional deficiencies, epidemics and vector-borne diseases has been widely recognized.[14] Government of India has recognized some of the principles and therapeutics of Ayurveda as a mode of intervention to some of the community health problems. These include Ksharasutra therapy for anorectal disorders, Rasayana Chikitsa (rejuvinative therapy) for senile degenerative disorder, etc. A list of the AYUSH drugs proposed in the IPHSs at different level of health care institutions is placed at Table 4.[14]

Table 4

Total number of AYUSH drugs proposed

Conclusion

With an abysmally deficient health infrastructure the role of AYUSH system in delivering health care services in the rural India is palpable. The grossly deficient health workforces in rural India are hugely replenished by AYUSH doctors and paramedics. Many of the therapeutics are being used in different forms for the management of community health problems which are safe and effective. Many of the principles described in the classical texts of Ayurveda and other systems of medicine such as Yoga and Naturopathy are being utilized and many of them are proposed in the state program implementation and planning (PIP). This scenario is not the same in all the states as health in India is a state issue. This problem has to be sorted out for the effective implementation of mainstreaming of AYUSH and revitalization of local health tradition in a more homogenous manner throughout the nation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.