Vichara

The health of the nation is in the hands of the medical profession. The President claimed in Parliament that the government spends Rs 6 million to produce a graduate MBBS physician. What is unfortunate is that around 500 doctors leave the health service to go abroad. The GMOA claims that in the first 8 months of this year 477 doctors left for foreign jobs. In fact, we are producing doctors for developing countries. It is impossible to stop this brain drain. More rats will leave the sinking ship. It will be fair to demand the personnel who abandon the country after receiving free education reimburse the cost of the education they received. Of course, that would not cover the opportunity cost of depriving another student of the training. To ensure that this condition is complied with, every internee should be called upon to enter into a legal agreement to consider that amount as an interest-bearing loan. The reimbursement will be less than 20 thousand dollars.

The cost of producing MBBS-qualified doctors is expensive and holding them to their post in the country is a perennial problem. This cannot be resolved by increasing the intake of students and providing more medical faculties. In the past, we had a cadre of medical practitioners named Assistant Medical Practitioners AMP (apothecaries). They provided a useful medical service in village dispensaries. But around 2015 on the objection of the GMOA that it compromises the the Standards of Medical Profession in Sri Lanka. Their main complaint was that the entry qualification to the AMP service was low, and they have not received proper training. It is proposed that this service is revived under any appropriate designation and given a Diploma level training. Following are a few observations published in research documents on the subject.

The history of Assistant Medical Officers (AMOs) in Sri Lanka can be traced back to the 1860s. Their training from the beginning followed an allopathic, ‘evidence-based’ model. AMOs have played a key role in rural and peripheral health care, through staffing of government central dispensaries ….Task shifting is a well-recognized cost-effective model for providing healthcare worldwide and is used in many lower-income countries as a means to expand access of care in critically underserved areas.” But in Sri Lanka, the AMO training programs were suspended in 1995 without research into their contribution, particularly in rural areas. One argument was that there was no longer a physician shortage in Sri Lanka so AMOs were no longer needed. https://www.researchgate.net/publication/236673824_The_assistant_medical_officer_in_Sri_Lanka_Mid-level_health_worker_in_decline

Different countries have begun to look to medical task-shifting as one way to address physician workforce shortages. Since the 1960s, the United States (US) has deployed over 80,000 Physician Assistants (PAs) .PAs have been characterized as …a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment…under defined levels of supervision.” https://www.researchgate.net/publication /235729641_The_physician_assistant_Shifting_the_Paradigm_of_European_medical_practice

When AMOs training course in Sri Lanka was discontinued in 1995, it was argued that the quality of care provided by the AMOs is substandard relative to that of physicians. The success, rapid expansion and integration of physician assistant programs into the US healthcare system have recently spurred other countries to introduce similar programs. The history of Assistant Medical Officers (AMOs) in Sri Lanka can be traced back to the 1860s. Their training from the beginning followed an allopathic, ‘evidence-based’ model. AMOs have played a key role in rural and peripheral health care, through staffing of government central dispensaries and maternity homes. Sri Lanka’s moved in the opposite direction, phasing out the AMO profession, without any research into their contribution to primary health outcomes.” https://www.researchgate.net/publication/236673824_The_assistant_medical_officer_in_Sri_Lanka_Mid-level_health_worker_in_decline

What is important is to identify precisely the job description of primary health care. First premise is that preventive care should take precedence. A layman’s opinion is that an MBBS qualification is not essential for this.

WHO and UNICEF defines Primary Health care as a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment.”

WHO defines the primary health workforce, as those engaged in addressing the social determinants of health and are engaged in the provision of diagnostics and treatment with referral to specialized services when needed. In many jurisdictions, these occupational groups perform a gatekeeper role to the health system. This is precisely the task of the AMO.

As far as treatment is concerned it is sad to say that most present doctors have lost the art of diagnosis. How can consultants in private hospitals make a proper diagnosis when they spend less than 5 minutes on a patient? Today most doctors depend on laboratory reports and antibiotics which could be used by AMOs as well without charging an exorbitant consultancy fee. What we need is more laboratories and laboratory staff.

We now have enough jobless biology stream graduates who can be given relevant, a Diploma level functional training and assign to field jobs as AMOs.

They will be less inclined to look for greener pastures abroad. This measure will also allow more space for MBBS-qualified physicians to train in specializations.

Vichara