Specialist Skills for Community Health Centres -
Breaking through the brick wall
- Conversation between Dr Yogesh Jain (YJ) and Prof T Sundararaman (TS)
This conversation is about one very specific “problematique” viz- the huge and increasing shortfalls of specialists in the Community Health Centres (CHCs). Over 80 percent of the specialist posts in CHCs are vacant. This is not a new problem. Every year, for as long as we can remember, when the annual Rural Health Statistics bulletin is published, there is a small outcry in civil society, the media and even within the government on the shortfall. This year this publication came out with a different title “Health Dynamics in India- Infrastructure and Human Resources” but the problem and the response to it was the same. Lamenting the problem does not solve it. The very persistence of the problem over the last two decades, and its countrywide nature must alert us to this being a design failure and not a mere implementation issue.
In this conversation Yogesh Jain, who has the lived experience of providing such specialist services as appropriate to this level, and Dr Sundararaman, retrospect and discuss the possible design flaws and how these can be addressed. And why addressing it is urgent, as the fate of primary healthcare hangs on the balance.
Background: The Community Health Centre (CHC) is a public health facility that serves the population of an administrative block which is a population of 100,000 to 200,000. Each CHC, is the first referral unit for three to five primary health centres or about 20 health and wellness centres (health sub-centres). It is the site nearest to the community for provision of secondary level care and any hospitalization services. And without such referral support, most primary level care is dysfunctional. To provide these referral services, the CHC is sanctioned a team of four or five specialists: an obstetrician /gynaecologist, surgeon, physician, paediatrician and often an anaesthetist as well. Along with this comes a complement of nursing and paramedical and technical staff. A number of administrative blocks together constitute a district. Each district has a district hospital which is also a site of secondary care and is designed for a larger number of specialists. India currently has 6359 CHCs and 714 district hospitals. There are also 1340 sub-district hospitals, other than the CHCs, and broadly this problem of inability to fill specialist positions, applies to most of these these sub-district hospitals also. (pg 39, GOI, MOHFW Statistics Division, Health Dynamics in India (Infrastructure and Human Resources), 2022-2023,). In many districts of better performing states, 100-bed Taluka Hospitals(sub-divisional hospitals) function as the first point to access specialist care for a cluster of blocks, and their experience could be somewhere between that of the district hospital and the CHC.
TS: Let me set out the problem. The current requirement of specialists for CHCs as per this publication, is estimated at 21,964. This is itself an underestimate. Of this, only 13232 (60%) positions are sanctioned and of this only 4413 are filled. This 4413 represents a 67 % vacancy rate and a 80 % shortfall rate. (Vacancy rate is vacant positions, as a proportion of sanctioned positions, whereas shortfall rates is vacant positions as a proportion of required positions). In absolute numbers the vacant positions increased by 150% between 2005 and 2023, and the shortfall in numbers increased by 180%. There are 17551 vacant positions in the CHCs, for just the four basic specialities. (this figure are from comparative statement 6, page 86, Health Dynamics of India). Though inadequate sanctioning of required posts is a problem, the bigger failure is the inability to fill up even the posts that are sanctioned. Departments cannot demand sanction of more posts when existing posts remain unfilled. Not surprisingly in better performing states, which are known for better administration, the sanctioning is itself low.
The basic design question is what is the specialist skill requirement for medical services at this population level, and is this served by having these four or five specialists in position? And is there significant harm due to the lack of required specialist skills. Over to you Yogesh.
YJ: I think this question is a very germane one. And I would start by saying, frankly, we don’t know how many specialists and specialized knowledge we require at a population of one to two lakhs level, or even at levels of a million or more, which is average district size. We don’t even know the patterns of illnesses and there’s no such formal prospective work that has been done to delineate this. We have a recommendation of two hospital beds for 1000 population per year, but such a recommendation is not there for outpatient secondary care requirements.
Based on lived experience of having worked in an under-served area over the last two and a half decades, and given the poor state of health determinants in large parts of India, one can state with confidence, that the requirement for specialized skills and knowledge in medical care is much larger than is available. But I would quickly jump into answering the next part of your question, which is to say that we have often conflated specialized knowledge and skills with a specialist. We think that we would need a person who is a clinical domain specialist, created by a three-year period of training or more, and most illnesses that fall in that each clinical domain would be managed by corresponding specialists. That is a moot point, and I think we could debate about this further. But when one looks at the number of such clinical domains, necessary for healthcare for a population of even 100,000, it would be to the tune of about 20 specialized areas. This is a large number to deploy in a CHC, or even at a sub district hospital level, and if so, deployed most specialists may not see enough cases in many of the domains to even retain their specialist skills. We understand that there are specialist positions for about 10 odd specialties at a district hospital level, and for others at a tertiary centre, like in a medical college. Even at the CHC level, we actually need domain expertise in at least 20 specialties. It would be impractical to staff CHCs with numerous specialists. To my mind, the only way forward to address the specialist skill gaps of the CHC (and much of secondary care), is to develop a “specialist” role with broader knowledge of many of these clinical domains…. more than an MBBS graduate but less than a three-year specialist.
TS: To put it another way. Even if we have these four specialists in place, we would still have a number of clinical skills which are essential at the CHC but which would be outside the clinical domains of these four. For example, in domains like mental health, orthopaedics, ophthalmology, ENT, nephrology, cardiology etc. Part of this problem lies in the nature of specialization itself. One becomes more skilled in a specific clinical domain and in parallel less skilled in many other related areas. Before orthopaedic skills were a part of general surgery specialisation, but now, as orthopaedics develops, general surgeons lose their competence in bone and joint diseases. Before with an MBBS degree, a fair amount of basic speciality practice could be done, but now MBBS doctors will come out with only the skills required to apply for specialist courses, rather than being able to treat basic clinical problems across a wide number of specialities. Conversely, if specialists as currently trained are placed at the CHC level, they are unable to practice what they think they are trained for because the opportunities in equipment, treatment etc, are not there and even the clinical cases are limited and they have to spend much time in generalist work. And every speciality is defined by some very high technology requiring diagnostics and procedures. Indeed, they are created with a different clientele in mind, and many specialists may be equally inadequate to manage many of the cases that a CHC handles. So, shall I say the current specialist courses are not really fit for purpose in terms of secondary care and that could be a barrier to recruiting them for this position?
YJ: I think what you say is, in fact, seminal. And I would add to this by saying that the position, the place, the role and the space for specialists of certain domains is only possible when you have adequate number of specialists of each domain available at a particular place, so that the entire whole requirement for specialized knowledge and skills are met with for a particular population, round the clock, round the year. District hospitals in states like Tamil Nadu and Kerala are able to do this for many specialities and this could expand. But for sub-district facilities it is neither feasible nor desirable.
Therefore, given the needs of health systems, we need to prioritize recruiting “multi-skilled” generalists and develop training and deployment strategies to meet this demand.
I challenge the very paradigm to focus on developing more specialists instead of multi-skilled generalists. Specialists are limited by their training, often unlearning other skills and becoming more costly to train and recruit. They tend to cluster in cities, serving privileged populations and lacking awareness of local socio-economic issues. Their technology-driven approach contrasts sharply with primary healthcare’s focus on community needs, perpetuating inequities in access. While specialists are important in tertiary and quaternary care, relying on them as primary providers in secondary care is ineffective and needs to change.
TS: There has been a massive expansion in professional education for postgraduate education in the last three decades, especially in the last 15 years. Why has this not helped in reducing the shortage of the CHC level? Why has the shortage actually gone up?
YJ: This is similar to the problem in case of MBBS medical doctors too. When I was doing medical training, the annual graduation in India was about 12,000. And now we create 100,000 doctors every year, and yet the geographic skew in the distribution between urban and rural and between the more and the less developed districts is worse than ever before. The problems are more with specialists, where training is expensive even in the public system. After the increasing privatization of post-graduate education in the last decade the specialist course has become so expensive that only the most affluent are able to access it. And thus, this strategy of pushing professionals to serve in rural areas due to pressures of a labour market, doesn’t seem to be working. And the fact that we don’t have a regulated private sector in healthcare means that those with specialist skills gravitate towards the private sector, and thus public systems continue to face the shortage of specialized skills, more so at their peripheral facilities, particularly CHCs and sub-district hospitals.
TS: Let me try to put it more in a sharper way. Increased number of specialists does not work because of the high cost of education, and the cultural background and expectations of those who are able enter specialist education. And then there is a pull factor, where a growing private corporate sector with features like medical tourism pulls specialists away from public service.
To some extent, states like Tamil Nadu addressed these problems and did better in recruiting specialists because it had reservation of seats for medical doctors in government service, followed by a bond they had to sign to go back and work in rural areas, plus an active process of placement. In another example in the private sector, the Christian Medical College, reserved seats for students nominated by rural parishes and from these nominations selection was made by an entrance examination. Selected candidates had a clear commitment to go back and work in Mission Hospitals in rural areas, and there was a system of placement. Taken together this package of measures works at least for finding specialists for district hospitals. Unfortunately, the coming of a coming entrance examination based on multiple choice questions for both undergraduate examinations (NEET) and for post graduate examinations has disrupted these processes that have served us well, over at least in parts of the country. for a very long time.
But let us consider one of the most popular solutions that are being offered to address this specialist crisis. Since most specialists are in private sector, public services could and should enter into public private partnerships where the private sector is contracted in to close the gaps. This could be through outsourcing CHCs or contracting in specialist. What’s your take on that?
YJ: Well. This has been tried extensively and is a complete failure. We have had this experience from several states in India like Uttarakhand, Karnataka, Rajasthan, Chhattisgarh. In Madhya Pradesh there are ongoing efforts. Most of the specialists in the private sector have made a choice based on the money they can make. We also allow private practice by public physicians. So whatever specialists we have in the public system continue to do private consultations. I am also concerned that the outcomes of complex disease that require specialist care are abysmally poor. To give an example most of our cancers are diagnosed at stage three or stage four, even where private sector access is provided. The current access to private sector does not provide for preventive care or even an adequate continuity of care.
TS: Yes. I think we now have extensive experience with PPPs that we should learn from. Let me share a case study of outsourcing of CHCs done in Uttarakhand which was built on this premise or using PPPs to provide access to specialist care. Contracting was done with the best of management consultancy advice that was available, and the contracts tried to ensure viability and profits and performance-based incentives. Contract packages bundled near-urban CHCs with remote CHCs so as to make the packages more attractive and viable. Higher salaries were also planned for. Nevertheless, after three years what became clear was that they just were unable to attract specialists to work in the CHCs. They could get some retired specialists and some interns- at both ends of the spectrum, but even that for some time. As the gaps in fulfilment of contractual obligations grew, governments withdrew, but given the secure contractual terms the private partner went to court. A common-sense understanding would be that when specialists are not willing to work as government employees with the remuneration and perks it carries, they are unlikely to be available for a contracted private health management organization on contractual terms. The reasons why specialists are not available for CHCs are more than a mere question of public or private ownership.
But let us consider another favourite alternative to close the specialist gap. Is telemedicine the solution? A lot of people keep saying that it is digitization and telemedicine could provide the access to specialist services without the specialist services without specialists having to be recruited and posted in CHCs. What would be your take on that?
YJ: I think that the scope of telemedicine has to be understood in the context of what, and how clinical diagnosis and treatments are made. Tele-consults, do now allow for direct clinical examination. Illnesses that deserve specialized knowledge and specialized skills can seldom do without physical examination. In some clinical domains like pathology or dermatology the visual image along with the reported symptoms may be adequate, but these are exceptions.
On the other hand, if there is a skilled provider on hand, like a well-trained generalist, who have done the basic work of evaluating illnesses at their primary care level, the specialist tele-consult would help provide such a primary care provider with support. Such consultations could be useful, but I don’t think it could ever be reduced to a direct “patient-to-tele-specialist” paradigm which I think is almost well impossible and not even desirable. Even a non-physician clinician directly talking to a specialist will neither be very effective or desirable.
TS: I would agree. I think that telemedicine does play a role as a backup for a qualified clinical provider for accessing higher level of skills and benefitting from a discussion. But healthcare is about a relationship of trust. The patient has to delegate the decision on what is best for his or health to a provider. Seeing the provider only across a screen is not really the conditions where one can build that level of trust. If patient develops such a relationship with a skilled provider, then the provider can be backed up by telemedicine consultation, but not the relationship with the patient. Telemedicine best supports the clinical provider, and does not substitute them, by directly reaching the patient. It seems therefore that the only viable solution we have for the CHC is a multi-skilled generalist or a basic specialist. something like a mid-level specialists- above the current MBBS, knowing some knowledge and skills from a wide variety of clinical domains but less than what the domain specialist would know. In some countries this is known as the advanced general practitioner post, or as a family physician- and the degrees are a MD in General Practice, or a MD in family medicine. So, what is the experience of the rollout of Family Medicine in India?
YJ: Before that Sundar, I have a question for you. Since you’ve been observing health systems evolve over the last four decades and since you also are aware of how health systems operate in many other both low- and middle-income countries. How did it happen that we chose the paradigm of having these four specialists in a CHC as the only route for providing first referral care, or secondary care. As opposed to so many other countries that that opted for universal health care on a comprehensive primary health care approach. Why is it that India took on this particular path? Did India ever consider this basic specialist as the option?
TS: Let me take the second question first. The National Health Policy of 2017 provides space for this development, even if it refrains by mandating this path. To quote in section on Specialist Attraction and Retention (para 11.3 page 16) which obviously refers to the CHC specialists gaps it state : “Proposed policy measures include…… up-gradation of short term training to medical officers to provide basic specialist services at the block and district level, performance linked payments and popularise MD (Doctor of Medicine) course in Family Medicine or General Practice………” Elsewhere in the policy it calls for creating new professional boundaries. Even, the National Health Policy 2002 had given considerable emphasis to developing such a professional to address the secondary care needs.
Why it was not implemented is always a difficult question to answer. But let me speculate a bit, based on the experience with the Family Medicine programme. A lot of our policy setting, especially when it comes to secondary and tertiary care gets taken over by the leading specialists of the leading medical college hospitals of the country. And though their domain knowledge and even intuitive problem solving in clinical domains is excellent, their notion of health systems is limited and intuitive knowledge can be misleading. Even during the articulation of the Indian Public Health Standards, this was not considered seriously. The CHC we imagined is a sort of truncated hospital which can be managed by a replication of their setting in a more abridged staff. Which is a pity, because India had a number of field hospitals, which were run by non-governmental organizations from which we could have learnt. Military too has had a number of field hospitals, and there were even many outliers in government facilities.
But let me ask you to elaborate on the alternative to the current set of five specialists proposed for the CHC? And on what experience do we base this recommendation of this family medicine specialist on?
YJ: So for me, a Family Physician or a General Practitioner (GP), as several countries have taken on is a “specialized” generalist. We must remove this conflation between specialized knowledge and specialists. I think it’s possible and several countries and some institutions within India have also done this. They have equipped a person who is a physician (MBBS medical doctor) with selected skills that come from multiple domains of specialization to create a specialized generalist or let us. And for me, family physician is a specialist.
Many countries have taken this option. UK is a model of GP, where more than 50% of all their specialists are GPs, which they define as a specialist in primary health care. This is a three-year course that they complete after graduating as MBBS and finishing their internship. All primary healthcare is staffed by such GPs. This is true for many high-income countries.
In Brazil too, the entire health system was developed on a family physician and a family health unit as the unit of their healthcare provision at at the community level. Many countries in South East Asia, especially Nepal and Sri Lanka have programmes of MD in Family Medicine or MD in General Practice, who perform secondary health care functions. Bangladesh and India are exceptions.
TS: What is the current experience in India with the Family Medicine/ General Practice Programme?
YJ: Over the last 15 years, India has been running Diploma in Family Medicine Programmes, which are accredited by National Board of Examinations (NBE). One specific form of this done in collaboration with CMC Vellore was used to build competence in government doctors in secondary health care and quite well. But this does not have any surgical skills. The MD in family medicine is now available in only seven or eight places. But even these programmes are sub-optimal because most of our tertiary care and medical college teachers are specialist-practitioners with limited or no experience of generalist contexts. We don’t have the right amount of family physician teachers.
But the bigger problem is that we do not have policy to recruit and deploy family physicians/GPs for secondary care. I don’t know of any public health system in any state of the country, which offers jobs to family physicians. It is worth noting, that partly due to your intervention and mine at the level of the health secretary, Mr Keshav Desiraju, Union Health Secretary in late 2013, brought out an order stating that the posts of specialists in the CHC could be filled by those with an MD or diploma in family medicine. This could have accelerated our progress towards UHC, but was soon forgotten.
I would have said that family physician trained doctors would be the best block medical officers for leading a team at a CHC level, with whatever other domain specialist that they can get. Nor have we chosen to have this post even at a district hospital level. So, while we have paid some lip service to the entire idea of family medicine, we have not learned from international experience and we have allowed the idea to be trivialized and sort of marginalized. One reason for this, in my view, is the push back from specialists who see the idea of a family physician as a threat.
TS. I note that when diploma in family medicine was approved by the medical council many corporate hospitals, started this course and allowed admission. But all the exposure and training that they gave to the candidate was as an assistant in intensive care. Far removed from what was required!! What was this phenomenon? How do we understand it? How do we cope with it?
YJ: Okay this was the private sector gaming the medical education system, simply because they know that residents who do post-graduate courses are extremely hardworking, and can be entrusted with more routine clinical tasks. So, several private institutions in Delhi and elsewhere in the country took on this course because it was being offered to anyone who had 100 beds, cheap, well-trained labour to run their services, whether it is an outpatient services, sitting like an outpatient clerk or running their ICUs, when the so-called super specialist were focusing their time on the high return procedures. They we are doing the same with some Ayurvedic physicians, and I am told that in many private hospitals, they could be managing the ICUs through entire nights.
TS. You yourself have been part of a training program for NBE certified diploma in family medicine; and in deploying them extensively. Is that correct? Could you give examples of how trained family physicians made a difference?
YJ: As someone who led this program for 10 years, I think this is actually very do-able. One obvious example, that has greater acceptance, is that a good family physician programme would enable the sub-district hospital and CHC to become a site of Emergency Obstetric care, including C-sections. The current short term training courses would get rolled into this. But such a GP/FP qualified person could also do many elective surgeries- including most of the perineal area common surgeries like haemorrhoids and hydroceles and hernias, the draining of abscesses. We know that traditionally, surgery has been a stepchild of public health, and that it should be a part of good secondary care. A well trained family physician is someone who would be able to make and confirm any diagnoses that current specialists do, undertake a wider range of basic surgeries, treat snake bites and scorpion stings adequately including put a child on a ventilator if needed for snake bite, treat a person with acute psychosis before referral and follow up based on the prescribed treatment plan, start treatment for multi-drug resistant tuberculosis, do the laboratory work that is required to support all of this and supervise and train his laboratory technicians adequately and so on.
To give another example, a family physician would not be able to do a cochlear implantation that an ENT specialist is trained to do, but is likely to see more foreign bodies in the ear, and outer and middle ear infections then even the usual ENT specialist. This logic occurs across all specialities. We could achieve such results with the programme run by CMC Vellore. And many other institutions in India have also shown that it can be done. I think we have to pre-empt this pressure from the specialist, who will always see such a professional entity as stepping on their toes and carve out this space for family physicians. Without which I can assure you universal access to secondary health care, or even a lot of appropriate tertiary care, would remain a challenge. . If we just follow the paradigm of having more and more specialists being churned out by our PG programs in the medical colleges, we are not going to reach anywhere, at least regarding secondary care.
TS. So, my question to you is, if our conversation reaches the powers that be, and family physicians for CHC becomes policy, what would be the best strategy to scale up in a short time? We need something like 18,000 to 25,000 family physicians who are capable of working in a CHC in, let us say, three to five years. We would also need some of these specialists in district hospitals. Could you suggest a national approach to scaling up?
YJ: Most of this training should take place in select district hospitals. We could choose a set of five or six domain specialists being teachers of these family physicians, and hopefully guided by some who are family physicians by training or by practice. About 50 percent of our 700+ district hospitals, many of which are upgraded to medical college hospitals would be good sites. I would even add to this, that they could even be a diploma in family physician, which could be offered to CHOs, or to medical officers working in PHCs.
I would envisage three or four family physicians working as a team in each CHC who are networked to each other across facilities, but also to the domain specialists who could be sitting at district hospital. These family physicians could also be the team leaders for the primary health centres and the health and wellness centres that they are providing referral services for. Further we can explore the option of family physicians becoming a jack of many trades and a master of one or two. For example, they could opt specialized training in psychiatry for nephrology/dialysis, or diabetology after certain years of practice. But this should be addition to the generalist duties they continue with.
But I want to come back to you with a bounce-back question. Why is there such resistance to creation of this multi-skilled physician, when we have readily agreed to a mid-level health provider (MLHP) for primary care (the CHO). We have put aside 12 domain areas of primary care to be done by the CHO and the team that they have. But when it comes to specialists the resistance persists. Are higher pecuniary interests being at stake, the reason for greater resistance?
TS: Creation of MLHP/CHO also met with considerable resistance. It was a two-decade long process. I wouldn’t say that it was so easily done. And therefore, I think we should persist with this struggle too, because the CHC speciality gap is not going to go away anytime soon, and we can put in place a better, more workable design. We also need to be a bit careful, because we had in between a bad experience with another experiment, the short-term courses for training medical officers in anesthesia and C-sections as part of preparing them for emergency obstetric care in the CHCs. This did not sustain. Part of the problem was the resistance from specialists, but a bigger problem was that providing the skills needed to go along with other supportive measures- a regularly functional operation theatre, and blood for transfusion, special neonatal care, quality assurance systems etc. These took time to develop, and it was difficult to create only for one service that would be occasionally provided. So just creating a specialist is not enough. You know, you require a whole ecosystem put in place. The best practice in this is how Nepal has been successfully deploying MDs in General Practice for providing comprehensive secondary care in the district hospitals.
YJ: Could you elaborate on that?
TS: In Nepal, facilitated by a unique NGO called the Nick Simmons Institute which is dedicated to this programme, the training and deployment of three-year trained GP has been ongoing since 2006. In fact, they had learnt of the idea from discussions within India But, they’ve gone far ahead.
In this approach a team of five persons are deployed in a district hospital by the NGO to complement the rest of the team which is in place. A district in Nepal is about the same size as a block in India. This team consists of one three-year MD in GP, one nurse is trained as an operation theatre assistant and can also do skilled birth attendance, an anaesthesia assistant with one year training, and a biomedical equipment technician with 18 months training. The latter could be placed at the provincial level. Now the district hospital can provide this enhanced package of services that covers all secondary care needs including surgery. It can have an expanded set of equipment with better assurance of maintenance. And at the end of a two-year period, these people have to be absorbed into the district hospitals. Over 40 district hospitals are covered by this programme. Now it is being scaled up to a 100 district and sub-district hospitals with MD-GPs also expanded. So, though this model is built around the GP providing care, it is conceptualized along with the support structures essential for functionality. The point being made is that the creation of a family medicine position will need to come along with other support requirements to achieve functionality.
YJ One question- who should be the preferred candidates to undergo this course and what should be their method of selection. In the programme I worked in, we were initially choosing motivated candidates. But once passing the entrance examination became mandatory even for the DNB degree in family medicine, the motivation of candidates joining this course dropped sharply and we had more drop-outs from the programme?
TS: I think priority should be given to medical doctors who are already placed in primary health centres, and who are happy to be placed and working in their current settings, and who have a commitment to working in that area. And this would be particularly valuable for the tribal districts and under serviced communities. The fact that this is a medical officer already working in that area makes, and wants to continue, not waiting for his transfer to come through makes it much surer that he is likely to continue,
But a corollary is that selection for this course cannot be a part of the nationwide medical PG entrance examination. Currently over 1,50,000 medical doctors write the PG entrance exam every year and of these 30,000 doctors or less will get a post-graduate seat. The desperation to get any PG seat is so high, that many doctors who have no interest in family medicine and who are most unwilling to serve as a secondary care provider at the CHC level will also join the course, and having graduated will drift away. The medical officer in rural service will have little chance of getting through this entrance examination, and that relates to the structure of the examination and not a lack of merit. So, we need affirmative action to ensure that the scaling up of MD in family medicine serves the purpose. One approach would be to make it very clear that this course is available only for working within public service and in a particular area, aimed to address a secondary health care gap as part of our commitment to universal health care. From its onset it should be outside the common entrance examination. We could therefore create this as a skill up graduation for serving medical officers’ pathway, with a different name, rather than just another post-graduate qualification. However, it would also be useful to offer these seats outside the service candidates, for building this up as a professional career in the long run. Another corollary: once medical officers acquired the family medicine degree their pay and perks should match those of the domain specialists.
Now Yogesh I am going to ask you a final question. Do you see this as an ad hoc arrangement made because we are not able to get specialists to work here or do you think the nature of this new professional entity is really a stable enduring solution that is required for many years to come?
YJ: Thank you for this question. Let me clearly state that I am not someone who is trivializing the need for specialized skills and knowledge in healthcare. We do require them for optimal outcomes for a large number of illnesses that everyone suffers from, and particularly the poor. Yet, I would say the direction of having such a “specialized generalist” is not just a pragmatic step to address existing gaps or an ad hoc agreement till we have adequate number of specialists in place. I see the family physicians as a health system choice to be able to give appropriate care, not only in countries with high inequity in access like in India, but in all countries of the world. And we know that many countries have already taken it on. I don’t see any other way that we can achieve universal access to secondary level care as part of a primary healthcare approach. It’s not, surely, an ad hoc arrangement. In fact, over time, like in UK it may not be limited to the CHC and could extend to PHCs as well. However, for now, the three-year degree course PG degree course in family medicine, with some surgical training would be the main pathway for closing the specialist skill gaps in the CHCs. And we must recognize that closing this specialist skill gap is essential for providing the referral support and continuity of care that are essential components of a comprehensive primary health care approach.
Note: In this conversation we have focussed on the skill requirements of the CHC. There is a need for a similar discussion on the approach to skill requirements of the medical officer in PHC and the Community Health Officer (CHO). Relatively more work has gone into these problematics. One positive practice that can be scaled up is the two- year diploma course in family medicine as a career progression pathway for all PHC medical officers. And for improving clinical and public health skills of Community Health Officers (CHOs)in an integrated way, there is already a very good NHSRC-CMC Vellore collaborative mentoring programme that was presented as one of the case studies in the WHO-SEAR collection that we introduced in the last conversation.
Acknowledgements:
Thanking Roubitha David for recording, transcription and edits and Shalini Singh for her peer review and editorial suggestions.
Lack of specialists at CHC is not a design failure but it’s essentially the implementation issue.
Truely we have never seen or realised the public health sector of country in totality as the people sitting in policy are having zero ground experience and they have been only a fancy visitors to these CHCs and PHCs which are the target of exploitation and worse management policies of state health departments waiting for a big reform along with huge improvement in general Governance of states in totality.
So doing such exercises on availability of specialist at CHCs is a waste of time and resources as these findings are already available with state health systems in country and they are unable to do a paradigm shift due to lack of vision in polotical rulers and parties and corruption and inactiveness in system since last more than 7 decades. So this pseudo analysis of public health system should be stopped immediately and better in case some model at ground of excellence are created for replication or wide scale adaption.
Dr R P Bhatt
CHAIRMAN , NNB Foundation
DG Health (retd)
Sir, it’s precisely such analyses that will bring about the changes in the system that are desired by Dr Bhatt.
Looks like he didn’t have a good sleep on the night of 29th September.
Thank you for this great conversation!
While a lack of specialists is an issue, a skilled generalist can manage most of the conditions. I believe India’s current medical education system is failing to produce even decent MBBS graduates. With the focus predominantly on becoming specialists, MBBS has lost its value and the attention it received even a decade ago when I started my medical education. You will now come across interns who can solve MCQs with 100% accuracy but do not know how to examine a patient and clinically reach a diagnosis. So while the lack of specialists is a glaring issue, I think a bigger issue is the lack of skilled generalists (MBBS doctors). The push to get MD/DM degrees as soon as possible has also taken the fun away from the MBBS learning as now the aim is only to crack exams by rote learning. The art of practicing medicine is dying (or is possibly already dead) in doctors from my generation.
Dr Parth
MD Community Medicine, MAMC (2022-25)
MBBS, CMC Vellore (Batch of 2014)
A much needed conversation that needs to be pursued repeatedly and widely. I wouldn’t say we should have skilled generalists only to ‘close the specialist gap’. In fact is it more challenging to be a good generalist than a specialist as the former has to wear many hats or be a vigilant soldier on a constantly tense border. Considering humungous gaps in our health care delivery system, a generalist is actually our Special Task Force. Given the scope of their skill sets-if supported and nurtured, they can be the most important gatekeepers from remote rural and PHCs to urban metros and Medical College Hospitals and hence true promoters of health and well being and providers of comprehensive health care. They were always there-good MBBS grads becoming good GPs but have been forgotten or reduced to dust. Not investing in revival of the skilled GP is rather a poor and insensitive understanding of well being of all.
Secondly, the picture is incomplete and very pharmaceuticalized and surgicalized if repeatedly we only talk about clinical skills and leave out those of diagnostics and rehab. Like now, these will continue to be silenced or of poor quality or inaccessible. USG is anyway speakeasy, Lab tests are questionable strip and card tests and rehab if at all is nothing more than ‘Take Care’. These life saving components also need to be given as much importance when designing training programs or curriculum for skilled generalists.
Dr. Sai Aparna J Sastry
Public Health| Health Administration | forwarded from LinkedIn
Very interesting read on the need for multiskilled generalists, Sir! Affirmative action in entrance exams targeting individuals committed to working in tribal and underserved areas truly seems like the way forward ! Thank you for sharing.
from Swami Subramaniam ( in LinkedIn)
CEO, Ignite Life Science Foundation, Clinical Pharmacologist, Neuroscientist, Product Developer, Author, Solving problems that hinder invention and innovation at scale
1w
We need this kind of reasoned discourse in public fora so that the right choices can be made. Sticking to legacy models will not make UHC possible. A radical transformation that upgrades the role of the frontline generalist supported through telemedicine is needed. Thank you for sharing this piece.
Nachiket Mor hope you check this out. Very relevant.
Thank you for highlighting this excellent discussion between these two icons. Their point that the need is much more for a multi-skilled General surgeon-type specialist than for a cohort of multiple individual specialists at the CHC level resonates strongly with me.
I am not persuaded, though, that their recommendation on how this will come about through a NEET-free / affirmative-action-oriented training program will be feasible in our environment.
I am much more drawn to their idea that the MBBS graduate can be equipped to do much more through learning and apprenticeship on the job in a CHC without the need to go somewhere, pass yet another entrance exam, and then train in a different environment. Tele-consultations between deep experts and the MBBS doctor can help fill in the knowledge gaps that may exist on an as-needed basis. The whole idea of Project ECHO began with such a thought (https://www.youtube.com/watch?v=A7XPc5dWKEk).
I think certifying people who acquire these skills in situ over time in multiple ways in a way that the FRCS does (no entrance exams, only competency-based certifications) may be more feasible for us both for front-line health workers and for MBBS doctors who are gaining the skills they need.
Nice conversation dear Dr Sundararaman and Yogesh..
There is acute need of generalistic specialist for primary care health setting. I hope Each standard dist hospital with specialis can be training centre for interested MBBS doctors..the faculty specialists can be trained as the medical college faculties..special examination can be conducted to see the skill improvement.. CMC Vellore and few other centres can be the faculty training centres and also evaluators of the trainees.. Carrier path should be inbuilt. At least there should be 30 essential skill development components including basic OG, gen. surgery, orthopedic and others in the course.
Forwarded :
from Gomathi Sundar • 1st
Director, Right Research Academy
Sundararaman T Sir,
What role do you think physician associates could play in CHCs? Given the success of PAs ( Physician Assistants) in tertiary care private hospitals?
Reply: Thanks for the question: Most physician associate programmes as I understand it are oriented towards task shifting a number of skills and functions that the tertiary care specialist requires support on. There is very little primary care level content and the requirements of support could be different. There had been discussion of multi-skilled support technical worker who can play the role of X ray, Laboratory and ECG and even ultrasound technician as required at at the level of a CHC- but thats a different topic. The current PA programmes are not so designed. But we have not thought deeply into this question- and these are only some preliminary thoughts.
Thank you for shedding light on this critical issue Sir. The chronic shortfall of specialist skills in CHCs and sub-district hospitals indeed poses a significant challenge to the effective implementation of comprehensive primary health care. The 80 percent shortfall mentioned in “Health Dynamics in India” reflects a deeper systemic issue that requires immediate attention.
From my experience in public health and health system strengthening, the lack of specialist support not only impacts referral systems but also breaks the continuity of care, placing an unsustainable burden on primary care providers. Addressing this gap requires bold reforms, including innovative training models, incentivized rural postings, and leveraging telemedicine to bridge short-term gaps.
It’s high time we reimagine our approach, drawing from successful models both nationally and internationally, to ensure we can transition from nominal Universal Health Coverage to a truly effective Universal Health Care system.