AYUSH Doctors Fill In Public Healthcare Gaps By Providing Allopathic Medicines

The sub centre in Deogaon was built in 2002 but it was never registered as one. Today, “the building is overrun with dust and is used to store hay”, the village head or sarpanch, Roshan Wade says. Vaviharsh’s centre was active until 2021, when snakes were discovered inside the building. Neither village has a permanent health worker to man these facilities.

“An estimated 600 million people in India, many in rural locations, have little or no access to good quality healthcare at affordable cost. India also faces a critical shortage of trained health professionals such as doctors, nurses, and allied healthcare workers,” says a 2017 mid-term evaluation of the National AYUSH Mission (Ayurveda, Yoga, Unani, Siddha and Homeopathy).

There are 20.6 healthcare workers for every 10,000 people in India, which is less than half the number recommended by the World Health Organization (44.5 per 10,000).

“National AYUSH Mission has several components which are aimed at promoting improved accessibility of affordable, quality healthcare as well as medical pluralism by integrating AYUSH into the state health services system and mainstreaming of AYUSH with allopathy,” the report says.

The government proposed to include AYUSH services in primary healthcare, as per the National Health Policy of 2017. Ayurvedic practitioners have been allowed to practise allopathic medicine after undergoing a six-month training since 2017-18, and Unani practitioners were included, with additional training hours, in the list of eligible professionals in 2019. There are about 755,780 AYUSH doctors in India at present. Including these takes India’s doctor-patient ratio to 1.83 doctors per 1,000 people, and makes India’s ratio higher than the WHO recommendation of 1 doctor per 1,000 people, as Minister of State for Health and Family Welfare Bharati Pawar told the Rajya Sabha in 2022.

Formerly known as the Department of Indian System of Medicine, it was renamed AYUSH in 2003 and a separate ministry--Ministry of AYUSH--was established in 2014. Successive Union governments have, since 2005, tried to mainstream AYUSH and use the doctors trained under these five disciplines as part of the cadre of healthcare professionals in India.

However, this move has been criticised by experts such as Shailaja Chandra, a former civil servant and author of a 2011 Ministry of Health and Family Welfare report on traditional medicine, and Kishor Patwardhan, a professor of Ayurvedic physiology at the Banaras Hindu University. “When the world is looking to India and in particular Ayurveda…for treatment for chronic conditions, unthinkingly opening wide the doors to practise Allopathy can derail and eventually finish Ayurveda,” they wrote in a 2018 paper.

India is among the 179 member countries of the WHO that have a Traditional, Complementary and Integrative Medicine (TCIM) system. India hosted the first ever WHO Traditional Medicine Global Summit in August 2023 in Gandhinagar. Attended by policy makers from 88 countries, it included discussions on strengthening the evidence base for traditional and indigenous medicine and the education and regulation of its practitioners.

In this story reported from Maharashtra and Madhya Pradesh, we look at whether and how the National AYUSH mission can help India improve its public healthcare access and quality. We find that where AYUSH doctors have been able to fill healthcare gaps, they do not practise the discipline of medicine for which they are trained, but more often prescribe allopathic medicines.

Why India needs more health workers

Traditionally underserved places such as Vaviharsh and Deogaon fall under tribal and hilly areas. While the public health sector faces a shortage of manpower in general, it is more acute in tribal areas, with a 13.7% vacancy in health workers in sub centres and primary healthcare centres (PHCs), according to the Rural Health Statistics 2021-22.

The PHCs to which the sub centres are linked are equally understaffed. Take the PHC in Phanda Kalan in Madhya Pradesh, for instance, which, in the absence of healthcare professionals, is run by Manish Mehra, a pharmacist.

Until 2021, his colleagues included an Ayurvedic doctor, an allopathic doctor, a pharmacist, an AYUSH pharmacist and two ANMs. At present, however, there is just one full time AYUSH doctor and two ANMs, one of whom was on field duty, and the other on her lunch break when IndiaSpend visited in May 2022. The allopathic doctor is attached to the Civil Hospital in Bairagarh and is available over the phone, Mehra told IndiaSpend.

A sub centre has to be manned by one female health worker or Auxiliary Nurse Midwife (ANM) and one male healthcare worker. There were 157,935 functioning sub centres in 2022, an increase of over 1.6% from the 155,404 sub centres in 2020 in rural areas, according to the rural health statistics report. There was a vacancy of 28,800 ANMs at sub centres in 2022 which was a decline of 38% from 46,864 vacancies in 2021 in rural areas. Meanwhile, there was vacancy of 34,476 among male health workers at the sub centres from 37,465 which is a decline of 8% in same time period as per the rural health statistics of 2021 and 2022

However, this marginal increase does not mitigate the critical issue. In rural areas, there was a shortfall of 3.1% of allopathic doctors at the level of PHCs, and a shortage of 79.5% specialists at the CHCs in 2022, according to government data.

“There are shortages of general physicians, especially in the remote and rural areas,” says Chhaya Pachauli, programme coordinator for Prayas, a Rajasthan-based health advocacy organisation. This critical lack of health professionals is leading to closure of many government health facilities, IndiaSpend reported in May 2022.

“Nobody wants to join public health services, because of the kind of limited facilities that they have, the long distances they have to travel to reach duty stations, and non-accessibility of basic facilities like accommodation, water, sanitation facilities,” says Anand Pawar, Executive Director of Samyak, a Pune-based organisation that works on advocacy around issues related to gender, masculinity, health and development.

Except for the positions of ANMs and male health workers, the number of vacant positions for healthcare workers increased across all categories between 2021 and 2022 in rural areas while there was an overall increase in vacancies in all categories in tribal areas.

The proportion of vacant positions for AYUSH doctors in rural areas has increased from 25.8% in 2020-21 to 26.6% in 2021-22. Similarly, there has been an increase in vacant AYUSH positions in tribal areas, from 21.8% to 30.8%, in the same time period from table above .

Doctors perform administrative tasks while patients turn to quacks

For the people of Deogaon, accessing healthcare is expensive because they are 29 km away from the closest PHC. There are private hospitals in Khodala (22 km) and a doctor has a private practice in Chandrachi Met (7 km). Each visit to the hospital in Khodala costs Rs 1,000-2,000, without including the cost of travel, said Wade, the sarpanch of Deogaon, adding that the doctor in the nearby Chandrachi Met village administers saline for Rs 500 irrespective of the ailment.

Instead of these doctors, people in Vaviharsh and Deogaon depend on local ‘witch doctors’ known as Bhagats. Wade says that given the distance and cost of accessing medical care, there is no option but to go to Bhagats.

“In case of emergencies like snake bites, locals go to the Bhagat first; if he gives up on the patient then they seek care in private facilities,” says Smitha Kirwe, the local ASHA worker.

“Around 80-90% of the people in villages will seek out the Bhagat first.”

Snake bites are fairly common in these parts, but not all snakes are venomous--a fact largely unknown to the locals, said Dokhe. Thus, in case of snakebites, they seek out the Bhagat, who “treats” them, and the patient thinks he has been cured--which reinforces the presumed abilities of the Bhagat in the minds of the people. “And when you have people who don't get cured, the Bhagat says the medicine did not suit them,” explains Dokhe.

The lack of basic facilities in rural areas makes doctors reluctant to serve. AYUSH doctors are willing to take up these jobs--according to Patwardhan, the Ayurvedic physiology professor--out of compulsion. “There is a scarcity of good jobs in AYUSH. But this is not how vacancies are to be filled.”

Better living conditions for doctors may encourage doctors to work there, said Tanuja Nesari, an Ayurvedic doctor and professor at the All India Institute of Ayurveda. “Facilities are being provided in rural areas and we hope people will opt to settle there on their own,” she said.

The result is a self-perpetuating downward spiral. Trained allopathic doctors don’t go to rural areas; this gap is filled by AYUSH practitioners who take up these posts out of desperation; that in turn affects the quality of healthcare available in such areas, Pawar says.

In places where trained healthcare workers are available, they have to do multiple jobs. In addition to giving medication to the patients who visit the PHC in Phanda Kalan, Mehra, the pharmacist, handles the paperwork, restocks the medicines, collects samples to send to the pathology lab in the Civil Hospital and also dresses wounds.

“I also have to drop off the attendance sheet at the district headquarters and fetch some things for the clinic, but there is no one present to handle this (the PHC) in my absence,” he told IndiaSpend.

On average, about 25-30 people from nearby villages visit the PHC in Phanda Kalan daily. The only doctor available full time in a staff of four, Seema Agarwal (48), treats them for complaints like piles, haemorrhoids, joint pains, infertility, irregular menses, etc. She is also saddled with paperwork, in addition to filling in for the ANMs if they are absent. “Vaccine bhi laga lete hain kabhi kabhi (sometimes, we administer vaccinations too),” she says.

Agarwal said that she chose to study Bachelor of Ayurvedic Medicine and Surgery (BAMS) because she did not clear the pre-medical test. “Private MBBS [Bachelor of Medicine, Bachelor of Surgery] degrees are expensive, so I enrolled to study Ayurvedic medicine instead.”

Of India’s 755,780 AYUSH doctors, 379,945 are trained in Ayurvedic medicine.

“My patients come to me asking for Ayurvedic remedies for their complaints,” she said.

As the medical officer, she has to attend sessions on allopathic medicine to keep herself up to date. However, she would have preferred if the government organised sessions for them on the technique of panchakarma (an Ayurvedic practice believed to rid the body of toxins) or yoga instead.

A 2009 study on the technique of panchkarma found that it has no effect on health, but it does improve perceptions of health among those who undergo the procedure.

How AYUSH doctors are trained, why the discipline needs more research

Alternative systems of medicine are regulated by different rules, according to Nesari, the professor at All India Institute of Ayurveda. “There is a law in place for these medicine systems. The National Council of Indian System of Medicine (NCISM) takes care of the education part. For each of these, there is a separate degree being awarded under the NCISM. The syllabi, entrance exam, etc. and the standards of education are being maintained,” she said.

Students who clear the entrance exams attend a five-and-a-half-year course. The subjects taught are parallel to those taught in allopathic medicine, including surgery, ophthalmology, gynaecology, etc., said Nesari, and the graduates are required to intern for the last year of their training.

But AYUSH doctors may not be equipped to handle all kinds of medical conditions under the present system of training. “During their course, they are not trained properly in anatomy and physiology in AYUSH. These subjects are taught by AYUSH practitioners who themselves are not trained adequately,” Patwardhan said.

Further, since AYUSH colleges do not have many patients, the scope for teaching is also limited, Patwardhan added. Noting that there are exceptions, he observed that the doctors “are not confident enough, and are not exposed to a wide variety of diseases”. Thus, the knowledge they gain is largely theoretical, not practical.

“There is no medical education policy research. PHFI is one organisation where this happens, but here AYUSH is not represented adequately. So evidence-informed policy is lacking in India,” he added.

All said, there is a demand for AYUSH treatments, according to Agarwal, and she provides both AYUSH and allopathic remedies to her patients as per demand.

AYUSH systems of medicine use ingredients derived from plants to produce drugs, which is similar to how allopathic medicine developed. However, there is no standardisation--while modern medicine uses a cause-and-effect framework to identify and quantify the effect of a medicine or treatment, AYUSH treatments can vary depending on the patient’s underlying conditions. This makes it hard to devise a fixed treatment for a particular disease, said Patwardhan.

“We (Ayurvedic practitioners) consider various aspects like digestion, strength of the patient, etc. and based on that we decide on a tailor-made treatment. This is difficult to distil into a protocol for trials. In modern medicine, there is one drug for one disease, which makes it easier to conduct randomised controlled trials (RCTs). This is how the regionality of the Ayurvedic system is preserved,” Patwardhan told IndiaSpend

“India is a diverse country with many variations among the people. For example in Kerala, a practitioner can survive by practising just Ayurveda. But this is not possible in UP and Bihar, where the population characteristics are very different,” explained Patwardhan.

Overall, the evidence base for Ayurvedic treatment is weak. Moreover, there have been reports (here and here) of poisoning caused by Ayurvedic medicine, which is similar to the adverse drug reactions in allopathy. However, unlike in the use of allopathic drugs where the adverse drug reactions are reported to prevent injury to patients, there is no regulatory authority for AYUSH drugs and remedies. Patwardhan blames the marketing of Ayurvedic drugs directly to the people for this. “Since the availability of proprietary drugs for AYUSH, there is no quality control for these drugs, but we are making efforts to rectify that.” The direct marketing of ayurvedic remedies to patients has also significantly damaged Ayurveda’s credibility, and more investment is required in research and development, he added.

Further, AYUSH disciplines are often used alongside allopathic medicine.

For instance, when the patients come to doctors with acute pain, they need to prescribe antispasmodics (painkillers used by allopathic doctors); surgeries under Ayurveda are impossible without anaesthesia, Patwardhan said.

About 89.8% of those respondents who used AYUSH measures for prevention of Covid-19 reported benefitting from the Ministry of AYUSH’s Covid-19 guidelines, Minister for AYUSH Sarbhananda Sonowal told Parliament on August 4, 2023. The results were based on the analysis of 1.35 crore respondents, of which 85% reported using AYUSH measures for prevention of Covid-19.

The research on AYUSH that the minister mentioned included prophylactic or add-on treatments. IndiaSpend has written to the ministry asking about the results of the studies and if there were any trials on treatment using AYUSH remedies alone, the number of surgeries performed in AYUSH departments of AIIMS Bhopal and the number of AYUSH doctors who practise AYUSH medicine. The story will be updated when they respond.

AYUSH doctors can help support public healthcare services, but more facilities needed

Inadequate training notwithstanding, in the absence of MBBS-qualified doctors, these alternative practitioners provide crucial and affordable services in both cities and villages.

“BHMS [Bachelor of Homoeopathic Medicine and Surgery] doctors and BAMS doctors are the only hope for people who are in remote areas,” explains Pawar of the health and reproductive rights group Samyak.

“They have been given some training, and these doctors have been playing a supporting role. Especially in outreach services, like counselling or meeting TB patients, and so on,” says Pachauli of Prayas. She also underscored the role played by AYUSH doctors during the Covid-19 emergency, when they were involved in management of patients and basic treatment.

However, increasing the number of doctors--AYUSH or allopathic--will not fix everything that is wrong with rural healthcare. “Expanding the provider base is important, but issues of accessibility and affordability will not be addressed just by adding more doctors. There is still a shortage of critical care services in rural areas. Just increasing the numerical strength of doctors may help with minor ailments, but for services like MTP (medical termination of pregnancy), people need assurance of quality,” said Pawar.

Appointing AYUSH doctors will not affect the quality of care available there, according to Pawar, because “they are the major providers in the rural areas and small towns” anyway. “If people use these services, the quality of service will improve.”

As of now, Agarwal has to cater to a population of almost 20,000 from villages near Sehore and Bhopal. To do this, she has a staff of one pharmacist, 17-18 ASHAs and no trained nurses. “If we had more staff, I would be able to attend to patients better, counsel them for longer and do a better job,” she said.

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