AYUSH and Health Services

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Policy and Practice in Maharashtra

Maharashtra’s policies for AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) professionals are discriminatory, allowing them to engage in “mixed practice” and recruiting them either as paramedics or as administrators in the general health services system, without ensuring equal status with their allopathic counterparts. It is in this context that the nature of engagement of AYUSH professionals with the state health system is examined.

Maharashtra, despite several a­­c­h­­­­­­­i­­­evements in healthcare, does not have enough opportunities for Ayurveda or homoeopathy professionals in the government healthcare delivery systems. The opportunities for AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) professionals to work as clinicians in healthcare systems have been confined only to AYUSH medical colleges and few AYUSH dispensaries under the zilla parishads. This is unlike the situation with other southern states, like Kerala, Tamil Nadu, and Karnataka, where the government healthcare delivery for AYUSH systems does have primary, secondary and tertiary levels for exclusive practice, with the medical colleges performing the role of tertiary-level hospitals. Within the private sector, there are very few AYUSH clinics and hospitals that ensure exclusive AYUSH practice.
The most “popular” practice of AYUSH professionals in the state is where they are appointed as doctors to “manage” ­allopathic clinics and nursing homes in the absence of allopathy doctors. This gets legitimised as “mixed practice,” a form of back-door entry into the practice of allopathy. This is supported by private hospital management offering designations as “resident medical officers” (RMOs), thereby ensuring “cheap” labour.
The Study
The present article is an inquiry into the historical policies and contemporary practices of the state health services towards AYUSH professionals. This is acc­o­m­­plished by analysing various records, circulars, orders, and guidelines of the health department pertaining to AYUSH. This information has been triangulated using interviews of selected professionals from the health services. Further, ­experiences of Ayurveda professionals working with the state health department have been captured by collecting information pertaining to their roles, ­responsibilities, and work environment in diverse contexts. The data was captured by the second author as part of her master’s dissertation that examined Ayurveda professionals’ engagement with the state health services system (Rai 2016).
The study was conceptualised at the state and district levels. The secondary data, in the form of government resolutions, recruitment rules, and guidelines were collected from the state directorate. Twenty in-depth interviews were con­­du­cted with Ayurveda and allopathy doctors engaged in clinical and administrative responsibilities along with paramedical staff at various levels of the state health system in the study district.1 These included the medical superintendent, district health officer, assistant and joint directors, and medical officers of health facilities at the primary, secondary and tertiary levels. The study was carried out in one district in Maharashtra and data was collected in April and May 2015. Further, informal discussions with BAMS (Bachelor of Ayurvedic Medicine and Surgery) and BHMS (Bachelor of Homoeopathic Medicine and Surgery) professionals from the state have helped us understand their professional concerns and priorities.
When one examines the origin of mixed practice within the private sector, it is shocking to find that it is only an extension of a government resolution (GR) of 1981 that legitimises Ayurveda professionals’ practice of allopathy. The intention of the resolution was to guarantee equal status to BAMS and MBBS (Bachelor of Medicine, Bachelor of Surgery) graduates in terms of work and opportunities for promotion in the health department. Acc­ording to the resolution, the “government has now decided to encourage e­ducation and research work in Ayurveda and to treat the Ayurvedic system of medicine on par with the allopathic ­system” (GoM 1981). This document has raised the prestige of Ayurveda professionals in the state and, for the first time, there were positions earmarked for them in the health services system as medical officers (MOs) in selected primary health units (PHUs). The resolution further states that:
Government is also pleased to direct that 25 percent of the total number of posts at primary health centres (PHCs) and primary health units (PHU) in the state should be ­reserved for and filled in by graduates in ­Siddha, Ayurveda who upon such appointment will be given class II gazetted status and pay scale, as applicable to their ­Allopathic counterparts. (GoM 1981: 2)
Even though the guidelines resulted in the earmarking of specific posts for Ayurveda graduates in the health dep­art­ment, these have also resulted in ambiguity in the role of Ayurveda profe­ssionals. This is because the expected role of Ayurveda practitioners appointed in primary health centres (PHCs) and PHUs was to practise ­allopathy “minimally,” as the drug ­supply was mostly of the allopathic kind. Administrative ­duties along with the imple­mentation of nati­onal health programmes were the added responsibilities in PHCs. This has resulted in ­better “acceptance” of Ayurveda graduates within the general health services system as MOs at PHCs.
After the “at par document,” the GR of 1981, the state government, in a gazette notification dated 25 November 1992, ­legitimised the eligibility of Ayurveda professionals to prescribe allopathic drugs. As per the gazette notification,
The Ayurvedic practitioners enrolled on the state register of practitioners of Indian medicine holding qualifications specified in parts A, B and A-1 of the schedule appended to the said Act, shall be eligible to practice the modern system of medicine which is known as the Allopathic system of medicine, to the extent of training they received in that ­system. (GoM 1992: 1)
This order was a historical moment for AYUSH medical practice, wherein it was for the first time that a state government had come out with an open declaration that medical professionals of other systems are allowed “to practise Allopathy to the extent of training they received.” This resulted in multiple interpretations of “extent of training” as it is very ambiguous. One of the major consequences of this was that there was rampant legitimisation of Ayurveda professionals’ practice of allo­pathy, which was earlier confined to only those PHCs and PHUs that were predominantly in underserved areas. In other words, what was earlier referred to as “quackery” in medicine in other states got legitimised in Maharashtra. Thus, acquiring an Ayurveda degree in Maharashtra became a licence to practise allo­pathy, which opened up a Pandora’s box.
The understanding of the differences bet­ween MBBS, BAMS, and BHMS doctors ­became blurred in the state, especially in rural and underserved regions, as there are no government Ayurveda or homoeopathy dispensaries or hospitals that exclusively practice their own systems and, in private practice, most of the BAMS and BHMS doctors prescribe allopathic drugs during clinical practice. This was also shared by several BAMS and BHMS professionals from rural areas, that when “they were to choose their profession after their 12th they were not even aware of these divisions, but they wanted to become a practising doctor and wanted to have their own clinics.”2 On further inquiry in the study district, it was found that the Ayurveda or homeopathy doctor exclusively practising Ayurveda or homeopathy, respectively, is rarely found in the rural areas of ­Maharashtra, which is also becoming a feature in urban areas. Not only were students’ aspirations of becoming AYUSH doctors triggered by their aspiration to practise allopathy in clinics, but these policy decisions also triggered the ­reciprocal growth of AYUSH medical ­education in the state.
Based on the experience of Ayurveda professionals practising allo­pathy, from 2000 onwards, there has been a demand from homoeo­pathy professionals to ­allow them to practise allopathy too. On the other hand, there has been opposition from medical councils of allopathy to mixed practice by AYUSH doctors, criticising the recruitment of Ayurveda doctors in the public sector. As a response to this, government policies were revised by prescribing restrictions and making recruitment rules more specific.
The candidate appointment to the post and possessing the qualification prescribed in the subclause (ii) (b) of clause (c) of rule 3 shall be appointed only at Primary Health Centres and Primary Health Units under the directorate and that 25 percent of the total number of posts sanctioned for PHCs and PHUs shall only be reserved for Ayurveda Graduate for appointment by promotion, selection and nomination in the ratio of 25:50:25 respectively. Provided that the total number of MO possessing the qualification specified shall not exceed 33 percent of the total number of MO in Maharashtra Medical and Health Services, Group A, (`8,000–`13,500) at any given time. (GoM 2000: 4)
This protected Ayurveda professionals’ space within the health department, but was discriminatory as it restricted their numbers as well as recruitments in higher centres at the block and district headquarters.
Experience of Ayurveda Doctors
In addition to their role as MOs in various health centres, Ayurveda professionals also work as health professionals under the National Health Mission (NHM) in Maharashtra, as they do in other states. Ayurveda ­doctors at the PHCs and PHUs usually ­report to the MO in charge, usually an MBBS professional from the same centre. Ayurveda MOs are recruited as Class II Group B MOs in permanent service, compared to Group A positions given to ­allopathy MOs, which is a reflection of the inferior status given to the Ayurveda practitioners. In order to provide primary healthcare services in tribal and remote areas where allopathy doctors are reluctant to work, Ayurveda doctors were appointed on a temporary basis, with their service contract renewed every 11 months, and were referred to as ad hoc MOs.
There are around 824 Ayurveda doctors working as ad hoc MOs across the state. Further, there are location-specific guidelines for the appointment of MOs in PHCs, recommending one allopathy and one Ayurveda MO in PHCs in tribal areas and two allopathy doctors in non-tribal PHCs. Thus, there are around 321 tribal PHCs in the state that are earmarked for Ayurveda doctors (Rai 2016: 39). On the contrary, it was observed (Table 1) that in the study district there were 33 PHCs (of which 15 were in tribal areas), five PHUs, and three dispensaries. In all the PHUs and dispensaries, and all the tribal area PHCs, the MOs were Ayurveda ­professionals and there was single MO in several of them. This is a usual pattern that can be found in other districts as well where most of the tribal area PHCs are manned by Ayurveda MOs.
An examination of the actual roles and responsibilities of allopathy and Ayurveda MOs in the study district found that these are similar and follow the PHC manual, though the signing authority lies with allopathy professionals, usually the MO in charge. Even though Ayurveda MOs are not officially trained and ­allowed to attend to post-mortems, medico-legal cases (MLCs), tubal ligation (TL), and medical termination of pregnancy (MTP), they have to do these functions in several situations, especially in the ­absence of allo­pathy doctors.
Despite this, the salary structure differs for MOs, as the basic pay for an Ayurveda graduate is `13,500, whereas it is `15,500 for an allopathy MO. There are no opportunities for promotion for Ayurveda graduates in the District Health Services (DHS), even if they have completed postgraduation. Currently, some Ayurveda MOs are getting a salary equivalent to Group A due to seniority, but their designation still remains under Group B.
There are provisions for Ayurveda doctors to get promoted to Group A (GoM 2000), though none of them ever reached the position of taluka health officer (THO), a promotion post for MOs of PHCs. Though several Ayurveda MOs hold an additional charge of THO in the absence of allopathy doctors, they remain designated as PHC MOs and are paid only for that post. When one of the state officials, a joint director from the DHS, was asked about the promotion policies of Ayurveda doctors, his response was more targeted at the clinical incompetency of Ayurveda professionals:
They are not capable enough and eligible to reach up to that post … they only do preventive services so how could they be involved in the clinical services … they can’t become CS [civil surgeon]/DHO [district health ­officer]… not even MS [medical superintendent]… at the max they can get a post like controlling officer if introduced in future.3
Working in dispensaries: Ayurveda professionals also work at the Ayurvedic dispensaries under the zillaparishads. AYUSH dispensaries are facilities that provide outpatient care, functioning in between a PHC and a sub-centre. Each dispensary is supposed to have one AYUSH MO, an allopathy MO and a pharmacist. As per the district Ayurveda extension officer4 of the study district, usually 50% of the AYUSH staff is contractual, but in our study it was found that 10 out of 12 MOs were Ayurveda professionals and were app­ointed in Group B on a contractual basis. The ­officer further added that “as per the ­recruitment rules all MOs are appointed for 11 months and Ayurveda professionals do not have scope for promotion.”5 In the villages, it was found that several of the dispensaries exist on the record, but do not function in reality. On the type of practice, one of the MOs shared that they are generally supplied with both allopathic and Ayurvedic drugs, and that they would practise according to the need. The following statement of an MO better reveals the standard practise that is prevalent: “If a patient is having fever, doctor gives Paracetamol and won’t wait for Ayurvedic medicine.”6 This reaffirms the fact that most of the zillaparishad dispensaries have also become sites for mixed practice.
National Health Mission: The AYUSH workforce is also employed for clinical services under the “Mainstreaming AYUSH” component of the National Rural Health Mission (NRHM) at secondary and tertiary levels. Administratively, they are appointed as part of the co-located facilities at district, sub-district and rural hospitals, and are expected to report to the district AYUSH Cell. Unlike earlier, it is expected that Ayurveda, homoeopathy, and Unani practitioners would practice their own system of medicine at each level so that one doctor from each system is ­expected to offer services in all facilities according to the local need. The exclusive clinical practice of their own system is expected when appointed under the co-location facility of the NRHM and is articulated in the guidelines of the AYUSH Cell (2010: 3):
Every AYUSH doctor is bound to practice his own system and should not be made to do emergency, Casualty, MLC (Medico legal ­cases), PM (post mortem) duties. AYUSH is a contractual post so they should not be posted at any other places. If any officer is found doing this, then he may be fined.
Despite this, AYUSH MOs are made to handle outpatient department (OPD), inpatient department (IPD) and casualty services without any training. At district hospitals, they have to conduct a one-month medicine OPD where they are compelled to prescribe allopathic medicines. There are no pharmacists and the drugs have to be dispensed by the doctors themselves at the community health centres. There is no infrastructure support available for the AYUSH wing, and staff and medicines are inadequate. The authorities are aware about the specific guidelines and its violations, but ­ignore them considering the lack of personnel in the system. With regard to the competency of Ayurveda professionals, an allo­pathy medical superintendent with 25 years of experience in the health services shared that “the amount of training received by an Ayurveda graduate during internship period is enough to handle any case, even in the casualty department.”7 Whereas, in another allopath’s opinion, “there is absolutely no comparison between Ayurveda and allopathy doctors as what the latter do is just a result of learning from doing.”8 All of them are of the view that Ayurveda professionals have to do this because the government has no other option due to the shortage of doctors.
The ambiguity that is prevalent among AYUSH professionals becomes clear from this statement of an Ayurveda PHC MO:
Ya to permission de do ya phir band hi ­kardo. … Bich me latke hue hai, … na idhar ke na udhar ke … PM karne ke liye mana kar diya hai par yaha par karna padta hai, MBBS doctor jaha available hai wo bhi yahi bhej dete hai. … Bali dene ke liye BAMS doctor ache hai, jaha jarurat hui waha use kar liya aur nahi to hata diya … Ek saal me 300–350 PM karta hu mai … jab se join kiya hai 1,500 PM kar diye hai … jab bhi court me case hota hai kuch to mujhe hi jana padta hai. [Either give us permission or stop this practice. … We are hanging in the middle, … we are not allowed to do PM (post mortem) but I have to do it here, even when MBBS doctors are available the body is sent to me. … We are the ones ready for sacrifice, we are used wherever they want us in whatever ways they want and thrown out after use … I conduct approximately 300–350 PM per year … so far I have done 1,500 PM … whenever there is a court case I have to go there.]9
The salaries of the AYUSH MOs under NRHM are fixed at `20,000 and `16,000 for those having postgraduate and undergraduate degrees, respectively, which are not even comparable to a clerk under regular health department. These MOs generally work at the grass roots where allopaths are not willing to work but are paid one-third of the salary paid to their allopathy counterparts. According to one of the MOs, “government gets three doctors in the salary of one.”10 They also face discrimination from their staff and other colleagues, like nurses and pharmacists.
National health programmes: In addition to the clinical services in PHCs, dispensaries and co-located facilities, Ayurveda doctors are working under national health programmes like the Rashtriya Bal Swasthya Karyakram (RBSK) and Maharashtra Emergency Medical Services (MEMS) as support staff for clinical services. The total number of Ayurveda doctors working for the RBSK is 2,119 and for MEMS is 2,225 in the state. Under the RBSK, Ayurveda doctors (one male and one female) carry out medical screening of children in anganwadis and government schools. In emergency medical services, the same Ayurveda doctors perform the duties of emergency MOs in ambulances, providing first aid to preserve life, prevent further injury, and promote recovery. An Ayurveda professional in Maharashtra has a sense of inferiority and ambiguity regarding their status, role and identity as a doctor, and that their role is getting diluted and they are being transformed into a new cadre of “multipurpose health professionals.”
Homeopaths for Mixed Practice
Homoeopathy professionals in Maharashtra also follow a similar trajectory to “legitimise” mixed practice as a way to achieve professional upliftment. The logic of allowing Ayurveda professionals to practise allopathy in the state is looked upon by homoeopaths as an opportunity to get “acceptance” within the government health services. Several attempts have been made by them in this regard. The initial period of formal teaching of homoeopathy in Maharashtra started with courses like the Licentiate of the Court of Examiners in Homeopathy (LCEH) in 1951, a four-year course which included the study of allopathy and ­homoeopathy, thus allowing them to practise allopathy till 1982. In 1988, the Bombay Homoeopathic and Biochemic Practitioners’ (Amendment) Act restricted them from doing so any longer. Further, in 2002 with a circular, the state prevented all doctors holding a licence ­under the Bombay Homoeopathic Practitioners Act, 1959 from practising allopathy (Janwalkar 2014).
Recently, with “Mainstreaming AYUSH,” an opportunity to officially enter into the government health services has emerg­ed for homeopaths. The homoeopaths’ ­attempt to get permission to prescribe allopathic medicines almost succeeded, with the Maharashtra legislative assembly passing this with a condition that those graduates wanting to prescribe all­opathic medicines would need to ­undertake a year-long certification programme in pharmacology (Tembhekar and Iyer 2014). Further, there has been a stronger demand by homeopathy professionals to set up a committee with orders from the state government for “resolving problems of homoeopathic medical professionals,” which resulted in the amendment of the Maharashtra Homoeopathic Practitioners’ Act, 1960 and the Maharashtra Medical Council Act, 1965 (Bansode 2015: 75). As a result of this, on 1 July 2014, Maharashtra took the decision to allow BHMS doctors to prescribe allopathic drugs after the completion of a one-year pharmacology course. On 13 August 2014, the Government of Maharashtra app­r­o­ved the certificate course in modern pharmacology for registered homeopathy practitioners in the state.
As per a notification from the Maharashtra University of Health Sciences (MUHS), in 2016, the said course, which is a part-time course of one-year duration, would be started in medical colleges affiliated to the MUHS, and for each college there would be an intake of 50 registered homoeopathy doctors (MUHS 2016). Acc­ordingly, 14 government medical colleges in the state, with an intake of 700 BHMS graduates, started this course from the academic year 2016–17. The preamble of the information brochure of this course states, “After acquiring this qualification Homoeopathic Practitioners will be ­allowed to use Modern Medicine in their medical practice to a limited extent” (MUHS 2016: 1).
Conclusions
State policy for AYUSH professionals has an important bearing on the very existence of these systems in any society. ­Maharashtra’s policy for Ayurveda professionals has resulted in the creation of a space for them in the health services, which was otherwise negligible across the state. Their engagements with health services reveal that they are losing their acceptance as medical professionals, and are rather seen as “multipurpose health professionals” who can be trained and transformed according to the needs of the system. Further, the ambiguity and discri­mination towards Ayurveda professionals within the health services is a clear indication of the mismatch between their professional training and their ­actual job responsibilities performed in the health services. The recent move of homoeopathy professionals on this path too is a strong indication of the larger question of role of AYUSH professionals in the health services.
What is the rationale of the MBBS, BAMS and BHMS courses being conducted separately, if the final expectations from these professionals are similar? Does the state believe that there is still scope for BHMS and BAMS professionals to be treated as AYUSH medical professionals who have something to offer as clinicians with a primary responsibility to heal the sick? If so, where are the ­opportunities for them to practise their exclusive systems in the future?
[The first author has prepared the first draft and contributed to the section on policies towards homoeopathy professionals. The second author has collected the data pertaining to the Ayurveda health system, especially the district-specific data, and contributed to the section on health services engagement. The third author is the mentoring author and has conceptualised the paper structure. The major findings is this article are drawn from the master’s dissertation of the second author, “Situating Professionals of Ayurveda in the Health Service System of Maharashtra” submitted to the Tata Institute of Social Sciences, Mumbai in February 2016.]
Notes
1 The study district has not been named as it can easily reveal the identity of several of the respondents at various levels, as there will be only one district Ayurveda extension officer, medical superintendent, etc, in the district.
2 Based on an interview with a homoeopathy professional who has also done his master’s and taught for some years in a homoeopathy college, May 2015.
3 Interview with a joint director, DHS, May 2015.
4 District Ayurveda extension officers are employees under the Directorate of Medical Education and Research (DMER) posted in the public health department. to monitor AYUSH activities. But, similar to other AYUSH staff, even they are considered as multipurpose workers (MPW) and engaged in regular activities of the zillaparishad under the district health officer. This was a one-time appointment by the DMER and the cadre has only about 23 staff in the state.
5 Interview with a district Ayurveda extension officer of study district, May 2015.
6 Interview with a medical officer, May 2015.
7 Interview with an allopathy medical superintendent of a secondary-level hospital at the block level, who has more than 25 years of ­experience in the health services, 16 May 2015.
8 Interview with a casualty medical officer (all­opathy) with five years of experience, May 2015.
9 Interview with a medical officer at a PHC who has been working in the health services for more than 15 years, 16 May 2015.
10 Interview with a medical officer at a sub-district hospital, May 2015.
References
AYUSH Cell (2010): “Guidelines for Provision of AYUSH Services in Public Health Facilities,” Letter No SHS/NRHM/AYUSH cell/implementation guidelines/10/21829-127, 21 October, National Rural Health Mission, Government of Maharashtra, Mumbai.
Bansode, Milind (2015): “Interpreting Government Policies towards Mainstreaming of AYUSH: A Health Services Systems Perspective,” unpubli­shed MPhil diss, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai.
GoM (1981): “Demands of Ayurvedic Students and Ayurvedic Graduates Decision in Respect of, Government of Maharashtra, Resolution No ADR-1080/104/PH-7,” 26 May, Urban Development and Public Health Department, Government of Maharashtra, Bombay.
— (1992): “Gazette of Government of Maharashtra, Reg no MH/Y-South/20, No CIM.1091/CR-179/91(Part V) ACT,” 25 November, Medical Education and Drugs Department, Government of Maharashtra, Mumbai.
— (2000): “Recruitment Rules–Medical Officer in Maharashtra Medical and Health Services Group A (Rs 8000–13500),” Government Resolution No RTR1091/CR 226SER3, 30 October, Public Health Department, Government of ­Maharashtra, Mumbai.
Janwalkar, Mayura (2014): “Homoeopaths with LCEH Degrees Can Practice Allopathy, Says HC,” Indian Express, 16 April, viewed on 20 July 2018, http://indianexpress.com/article/india/india-others/homoeopaths-with-lce….
MUHS (2016): “Information Brochure (Revised) Academic Year 2016–17 ‘Certificate Course in Modern Pharmacology’ for the Homoeopathic Practitioner’s in the State of Maharashtra,” ­Maharashtra University of Health Sciences, Nashik, 4 May, viewed on 20 July 2018, https://www.muhs.ac.in/showpdf.aspx?src1=upload/Information_Brouchure_Mo….
Rai, Jyoti (2016): “Situating Professionals of Ayurveda in the Health Service System of Maharashtra,” unpublished MHA diss, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai.
Tembhekar, Chittaranjan and Malathi Iyer (2014): “Now, Homoeopaths in State Allowed to Practice Allopathy,” Times of India, 10 January, viewed on 20 July 2018, http://epaper.timesofindia.com/Repository/getFiles.asp.
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