Over 6 decades of the freedom but still the plight of primary care for the people in rural areas still remains a dream to come true. Most of the PHCs are either not having proper human resource or not having good infrastructure (As per the Indian Public Health Standards (IPHS).The fact that accessibility and availability of healthcare for the people in rural areas is just to their fate. Most of the healthcares to the rural areas are still provided by Quacks or traditional healers. When we enjoy the high quality of care in the urban areas it is also our responsibility to provide at least the basic care in the rural areas.
This is in reference to a report published in the Times of India about the PMO office worried about the poor Doctor patient ratio on date 6 March 2012 and in response to the Government plans to start the Rural Medical Graduate program (3 years).
The Times of India report indicates that there is one doctor for 1,953 people, or a density of 0.5 doctors per 1,000 populations coupled with acute shortage of nurses and health delivery personnel.
HLEG says in 2011, India had 6.12 lakhs registered allopathic doctors. It will take the nation at least 17 more years before it can reach the World Health Organization's recommended norm of one doctor per 1,000 people. The HLEG has predicted the availability of allopathic doctors to one doctor per 1,000 people by 2028 that can be achieved by setting up of 187 medical colleges in 17 high focus states during the 12th and 13th Plan.
However there is no recent data on the situation of the demand and supply of physiotherapist in India. The international literature shows the need as 1:1400 and in developing countries the situation is more critical with an estimated average therapist: population ratio of 1:550,000. In some countries the situation is dramatically worse; for example, in India the ratio is 1:1,215,000 (Peat, 1990). In India we have over 70,000 physiotherapists working and many travel to overseas due to poor working condition in India.
Physiotherapy has been as a recognized profession in India from the post Independence period, but they are do not have any council to regulate and monitor the quality of education, services and issues related with their employment. Documentation about Physiotherapy is mentioned in the Bhore committee report (Clause 163/clause 175), but at that point of time country had no policies for the professional education and monitoring of physiotherapist. Although many states have already recognized the importance of the issue and has introduced councils to monitor the education and practice of Physiotherapy in states like- Maharashtra, Madhya Pradesh, Karnataka and New Delhi.
The Planning commission of India (2007-2012) point number 3.1.104 states that “In the field of paramedical education, priority will be given for establishment of National Para Medical Council as an apex body to determine standards and to ensure uniform enforcement throughout the country. On similar lines, councils for physiotherapy and occupational therapy should also be established” (Reference: Page 84 and 85 –Eleventh Five year Plan (2007-2012)_ Vol 2 –Social Sector Eleventh Five Year Plan(2007–2012)Social Sector Volume II-Planning Commission of India)
There has been huge documentation done about Physiotherapy in the Thirty-First report on Paramedical and Physiotherapy Central Councils Bill-2007 (Presented to the Rajya Sabha on 21st October,2008 and laid on the table of Lok Sabha on 21st October,2008).
Physiotherapist have study all necessary subjects that are the requirement for the basic medical education, however their training is confined to the physiotherapy discipline. The fact that the country has a huge shortage of human resource can be addressed to some point if we train the graduates with 4 ½ degree towards the public health problems in India. There is also a need to modify their course curriculum to 4 ½ of academic learning and a one year of internship. Within this period we may train them in their specialty and also look for training them in the Public health problems. The training would enable them to handle the public health problems and would thus help as a resource towards fulfilling the gap between the requirement and need of the health professionals.
The Alma Ata Act -1978 stresses that PHC should act as a preventive, promotive and rehabilitative services, which still we are not able to provide. The inclusion of Physiotherapist at PHC would facilitate these goals and the public health problems.
PT and PHC
A review of international literature indicates rehabilitation providers, including Physiotherapists are participating in many PHC in much health care system in many countries( England,Scotland,Ireland,Wales, Netherland, Swedan,Norway, Finland,USA,Canada, Australia and New Zealand). The paradigm of the practitioner who has the initial contact with the patient is shifting away from the traditional roles. There is evidence for expanded roles for PT that require strategic thinking, a clear vision, effective planning, outcomes measurement and the continuing development of competencies.
PT role in PHC
As self regulated, direct access health care professionals, Physiotherapist provide an increasingly comprehensive range of services across the continuum of care, including assessment, treatment, health promotion and prevention, supportive care, palliative and referral. Physiotherapist’s play important role as core team members in a wide range of Interdisiciplinary teams. PHC reform provides opportunity to replicate a similar role in PHC in those communities where priority majority population health needs are a match with competencies of PT.
Source: PHC and Physiotherapy (2005) Canadian Physiotherapy association, Position paper
Some of the role of PT in PHC is:-
1. Diagnosis and treatment of acute and chronic condition.
2. Chronic Disease management
3. Self-Management educator
4. Case management
5. Health promotion and prevention across lifespan- individual and community
6. Education/consultation to other health professionals
7. Research/Education/Policy
Benefits of PT in PHC
1. Facilitate right care at right time
2. Reduce cost of service
3. Reduce number of visits by increasing patients commitment and capacity to mange self
4. Reduce waiting time of patients waiting for specialist
5. Facilitate early discharge
6. Optimize and maintain functioning independence and safety.
7. Decrease load on the General practiosner.
Regarding the Rural Doctors
We appreciate the government’s initiative to start the rural medical graduates program but at the same time we would like to share our opinion:-
- By this move government would be preparing a new set of healthcare professionals that would be semi trained professionals, why do we not look at the trained professionals already available?
- How would the government ensure that after completion of the course the person is going to work only in the rural areas?
- A new set of infrastructure and finance would be required to train these professionals but why do we not look at more cost effective way towards the training and inclusion of Physiotherapist?
Bhore committee in its recommendation had mentioned that INDIA needs social physicians, where do we have the social physicians? It is still a concept we are not able to meet. Physiotherapist training includes training in the medical, rehabilitative and social areas of patient care could be a successful model for the care of the patients.
We hope that the Government of India would take a collective decision of including Physiotherapist at PHC which would help in decreasing the burden of disease on the country and would help to fulfill the gap due to lack of human resource. There is a need for a wiser decision to be taken does the country need to wait for 17 years to get the proper human resource staffing or are we looking at solving the problem with additional training to the Physiotherapist and their inclusion in the health care delivery system at PHC?
All of these goals may not be meet but atleast the government may look towards providing larger equity to the major section of the society which are the high vulnerable groups.
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