Critical comments on “Allopathic, AYUSH and informal medical practitioners in rural India – A prescription for change”

Dear Editor,

Congratulations to JAIM authors, Chandra S and Kishor Patawardhan [1] for bringing forth the issue of usefulness of AYUSH doctors in rural health sector. However, some of their inferences need reconsideration as discussed below:

Using National Sample Survey 2011–2012 quoted by Rao et al. [2], the authors question the role of AYUSH doctors in rural public health sector and claim to expose a subterfuge that AYUSH doctors work in tahsil and villages whereas actually they do not and will not. The survey has derived the density of Ayurvedic doctors as 0.2 per 10,000 populations as against the actual density 3.57 per 10,000 population as derived from their registered number 4,38,864 on 01-01-2012 [3]. Too small sample size (Allopathic Doctors 221: Rural 57 and Ayurvedic doctors 49: Rural 18 makes this survey inconclusive and the density too unrealistic as against their actual calculated density. The urban rural difference of giving service for Allopathic doctors is 11.4 times higher whereas for Ayurveda doctors it is 7 times higher [2], which shows that in comparison, Ayurvedic doctors are giving more services in rural areas. The high density of both services in urban areas is indebted to the remunerative advantage.

• 1.Utility of AYUSH facilities

The opinion that AYUSH dispensaries are of little use to villagers suffering from acute medical conditions as shown by low outpatient attendance [4] doesn't hold good on the background of Maharashtra, where the number of out patients attending PHCs in the state has been seen increased from 2,26,32,292 in 2012–13 to 3,54,56,483 in 2017–18 [5]. The rise in this attendance is partly indebted to Ayurved doctors holding 33% of posts of Medical Officers in the state, principally located in tahsils and villages.

• 2.Competency of AYUSH practitioners

A study of PHCs in Chattisgarh quoted by the authors [6] questions the competency of Ayurvedic doctors and their ability to manage modern medicine public health facility. This study has inferred that 51% prescriptions of Ayurvedic doctors as against 61% Allopathic doctors met the appropriate standard. Despite poor of quality of AYUSH education in Chattisgarh, AYUSH practitioners are meeting this standard. This doesn't prove them incompetent as construed by the authors.

• 3.Contractual AYUSH doctors in PHC

In conclusion, it was stated that contractual AYUSH doctors refuse to work in remotely located PHCs is not supported with any statistics. It doesn't hold good especially in the face of related statistics in Maharashtra, where in, 1019 Ayurved doctors are functioning on regular appointments as Medical officers, mostly in remote rural areas as on 31st Oct 2017 [5], in some cases as sole in-charge, performing all the duties of an In-charge Medical officer, including Medico-Legal duties. These doctors are appointed to deliver allopathic services.

Failure of AYUSH services to show their impact can be solely attributed to their negligence by the Govt. agencies, glaringly visible in AYUSH Minister's reply to parliament, which reads that since 2015–16, i.e. in three years under National AYUSH Mission; only 37% funds allocated to states by the Govt. of India have been utilized. Assam, Bihar, Jharkhand, Meghalaya have not used a single rupee and Maharashtra with largest AYUSH man-power (1,47,836) [8] in the country, has spent a meagre 1.1% (Rs. 39 Lakhs) in three years [7]. Incidentally, State health budget is handled by Directorate of health headed by an allopath and Secretariat by a bureaucrat.

Maharashtra experience indicates that equipped with appropriate drug supply and infrastructure, AYUSH doctors attract good number of outpatients, where they are appointed to impart allopathic services, however they scarcely get such support. Under the circumstances, a dire need is felt to establish an independent parallel Ayurvedic health care service sector in the States.

• 4.AYUSHMAN BHARAT program and AYUSH doctors

AYUSHMAN BHARAT program has two components National Health Protection Scheme (NHPS) and Health and Wellness Centres. NHPS doesn't acknowledge AYUSH doctors or drugs as they do not qualify empanelment [9].

In the second component of establishment of Health and Wellness centres (SHC), downgrading AYUSH doctors to a level of Nurse, the scheme recommends appointment of Nurse Midwife (B.Sc./GNM) ahead of Ayurved doctor as in-charge, who is expected to serve as Mid-level health provider at this centre (SHC) [10]. Moreover, Ayurved practitioner if considered has to undergo a six months training to qualify for this appointment. In Maharashtra, in addition to training, this practitioner has to pass an examination to qualify for this posting.

• 5.Independent entrance examination for getting admission to AYUSH courses

Organization of separate entrance examination for Ayurveda, as suggested by Sujatha V [11] will bring academically poor students to Ayurved. Presently academically better students ranked just below the students admitted in MBBS, take admission to Ayurved through a common entrance examination. In the past, an experiment to admit 10th std. students to Ayurveda has miserably failed. The motivation of the students depends on the academic ambience and not on mode of entry.

• 6.Need of special skills and clinical competencies in AYUSH doctors for treating NCDs

AYUSH systems particularly Ayurveda is not a disease oriented system. No separate skill or competency is required to prevent or treat non-communicable diseases. Any genuine and well learned AYUSH practitioner will be able to treat NCDs successfully.

• 7.Enrolment and accreditation of auxiliaries in medical register

Appropriately trainedAYUSH doctor equipped with appropriate facilities and adequate salary is likely to be a far better option than to expose rural population to half trained UMPs. Ayurvedic doctors equipped with needed infrastructure, medicines supported with adequate salaries through Govt agencies or on their own or through private organizations will prove more useful in rural areas. In cities many Ayurved doctors, as first contact in emergencies are proving very useful and effective in intensive care units in private hospitals. This proves Ayurvedic doctors with appropriate training can shoulder the responsibility of taking care of acute illnesses in rural area. Therefore, training unqualified medical practitioners and placing them in rural areas in place of Ayurveda doctors doesn't appear good.

The above facts need to be considered seriously before questioning utility of Ayurved doctors in rural health services.

Conflicts of interest

None.