Enabling prescription by

MID-LEVEL
HEALTH WORKERS
IN INDIA
POLICY BRIEF
ISBN 978-92-9022-882-0
© World Health Organization 2021
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 illness, disease, and impairments) or
Introduction
engages in preventive care and health
§ This policy brief outlines policy options,
promotion.” Mid-level health workers
policy recommendations and
are also those whose training has been
implementation suggestions to
shorter than doctors (2 to 4 years) but
operationalize mid-level health workers’
who perform some of the same tasks as
(MLHWs) prescription in India.
doctors.ii,iii
§ Such an initiative is also an opportunity
§ A systematic review carried out by
to strengthen workforce response in
Global Health Workforce Alliance, WHO
providing primary health care in
in 2013 on the role and performance of
pandemic situations such as COVID-19
MLHWs in the delivery of essential
and during other epidemics.
services found that MLHWs play an
§ A global systematic review of the important role in the delivery of maternal
literature and legal analysis related to and child care, antiretroviral therapy,
MLHW prescription was carried out. health promotion and prevention and
Indian case studies of Chhattisgarh and care for non-communicable diseases
Assam and international case studies of (NCDs). Noting the limitations in the
South Africa were also carried out to quality of evidence on available studies
generate suggestions for implementing on the performance of MLHWs, the
MLHW prescription in India. This brief is review concluded that the quality of care
based on the data obtained through by MLHWs for essential services is
various study components. comparable to the quality of care
§ The structure of this brief is as follows: it delivered by doctors.
describes the problem or policy § The National Medical Commission
challenge and moves on to presenting (NMC) Act 2019 in India has already
policy options on specic dimensions introduced the model of Community
such as legal changes, pre-service Health Providers (CHPs). Section 32 of
education/training, and model of the NMC Act states that the NMC may
prescription. A list of policy provide limited licence to practice
recommendations is presented that medicine at mid-level as a community
emerges from the examination of the health provider, to such persons
i
policy options. connected with a modern scientic
§ This brief also presents implementation medical profession who qualify such
considerations to be kept in mind criteria as may be specied by the
(related to medicine lists, in-service regulation. The CHP may also prescribe
training and stakeholder consultation) specied medicine independently, only
followed by specic implementation in primary and preventive healthcare.
suggestions. The regulations which would clarify the
scope of practice have not yet been
§ A WHO review denes a MLHW as
prepared/nalized.
follows: “A mid-level health worker is not
a medical doctor, but provides clinical § The enactment of the NMC Act, 2019 in
care (may diagnose, manage and treat India and the imperative of working out

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 the specic details needed to absent, there is a need to clarify the
operationalize the CHP system create scope of practice and range of
the need to study insights from a global medicines that can be prescribed by
iv
context and domestic experiments in them.
the domain of MLHW prescription. Such § Section 32 provision in the NMC Act,
insights can give direction to the 2019 led to a strong reaction from the
implementation of the system and the Indian Medical Association, which has
draft regulations being prepared. described it as ‘legalized quackery’. A
nationwide strike of doctors took place
Problem description after the legislation was passed.
Obtaining the support of this major
§ In India, on average, one government
stakeholder is essential for the legally
doctor serves more than 11,000 people,
sustainable implementation of MLHW
ten times more than the WHO mandated
prescription in the country.
doctor: population ratio of 1:1000.
§ At present, only medical practitioners
§ The rst point of contact in India
can prescribe medicines. The sale of
between the community and a
medicines based on a ‘valid
government doctor (medical ofcer) is
prescription issued by a medical
at the level of the Primary Health Centre
practitioner’ is governed under the
which on average serves a population of
Drugs and Cosmetic Act, 1940 and the
30, 000. There is, therefore, a need for a
corresponding rules (there is however
cadre of MLHWs to provide regular
no denition of “Prescription” in the
outpatient services closer to the
Drugs and Cosmetics Act).
population, at the level of the Sub-
Centre, which serves a population of § In 2014, the Union Cabinet approved a
3, 000-5, 000. three and a half year Bachelor of
Science in Community Health (BSc)
§ The Government of India has
course. This was aimed at training mid-
announced that 1, 50, 000 Health and
level health professionals with an
Wellness Centres would be created by
aptitude in public health and ambulatory
2022, by transforming the existing Sub-
care to serve the rural population at Sub-
Centres and Primary Health Centres to
Centres. However, the implementation
deliver comprehensive primary
of this course was ridden by certain
healthcare. This creates the need for
obstacles and the course could not take
suitably trained workers to staff the
off in India.
MLHW (Community Health Ofcer or
CHO) positions in these Health and
Wellness Centres. These functionaries Policy options
are expected to provide clinical care as
specied in care pathways and
A. Legal changes
standard treatment guidelines. Since § This section explores the policy options
they would provide clinical care in for legal changes required to implement
remote settings where doctors would be MLHW prescription in India.

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 However, recognition of the degree is
Denition of Amendment of not sufcient to permit the graduates to
CHP in rules to Drugs and
practise medicine. The next legal step is
NMC act Cosmetics rules
recognition of the Right to Practise
Medicine. The draft clause for the same
MLHW legally is proposed below (for inclusion in the
empowered to draft rules to the NMC Act).
prescribe
Any person who obtains a degree
Fig. 1. Policy options for legal changes recognized in the Schedule of this
Regulation shall be granted a license to
practice primary and preventive medicine
Policy option 1: Introduce a suitable
as a Community Health Provider and shall
denition of a Community Health Provider
have his/her name and qualications
(CHP) and clause for recognition of Right to
enrolled in the Community Health
Practice in the Draft Rules of the NMC Act,
Provider National Register maintained by
2019.
the Ethics and Medical Registration
§ In Section 32 of the NMC Act, 2019, it is Board under Section 31 of the Act.
stated that a CHP should already be
connected to an existing modern
scientic medical profession, and the Policy option 2: Include the denition of
CHP is allowed a limited license to prescription in Drugs and Cosmetics Rules,
practice which includes limited right to 1945.
prescribe medicines. The following § At present, medicines can be
recommended denition of CHP should prescribed only by medical
be included in the draft rules/ practitioners in India which includes
regulations for the NMC Act– “Persons dentists and veterinarians.
connected with modern scientic
§ The proposed denition of a
medical profession” includes a person
prescription to be included in Section 2,
who has completed the training under
Drugs and Cosmetics Rules, 1945 - “A
any degree programme recognized
prescription” is an authorization to
under the Schedules of this Regulation.
dispense drugs issued by- (a) a
§ Such a denition can enable registered medical practitioner, (b) a
introducing CHP courses at a registered dentist, or (c) subject to
Bachelor’s level, and quality control Regulation for Community Health
through a minimum degree Providers issued by the National
qualication. Medical Commission, a registered
§ Under the NMC Act, any new medical Community Health Provider for the
course requires approval from the medical treatment of an individual.
National Medical Commission.

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B. Education and training (pre- which implemented MLHW systems
since the early 2000s. The MLHWs
service)
known as Rural Medical Assistants
§ This section explores alternative
(RMAs) in Chhattisgarh were placed in
educational models that have been
Primary Health Centres (due to the
used in different developing country
absence of doctors or medical ofcers
contexts to train MLHWs.
in these facilities) whereas the MLHWs
known as Rural Health Practitioners
Degree (RHPs) in Assam were placed in the
Three to Six month
course Sub-Centres.
four year bridge
diploma course § Assam’s Diploma in Medicine and Rural
Health Care (DHRHC) for training RHPs
was a three and a half year course
MLHWs trained
to prescribe (including a six months internship) while
Chhattisgarh’s Practitioner in Modern
and Holistic Medicine (PMHM) for
Fig. 2. Alternative educational models training RMAs was a four-year course
for pre-service training of MLHWs
(including clinical postings and a one-
year internship at Sub-Centres, Primary
Policy option 1: Three to Four Years
Health Centres, Community Health
Diploma Course
Centres and District Hospitals). Both
§ Nigeria has a four-year direct entry these courses had a ‘compressed
viii
diploma programme in community MBBS’ course design; the major
health, (trained nurses may opt for a difference in MBBS was the absence of
three-year diploma). Uganda has a topics such as forensic medicine and
three-year Diploma in Clinical Medicine major surgery in the MLHW course.
and Community Health with two years of
§ A study of the diploma-trained RHPs in
internship. Kenya has a three-year
Assam by the National Health Systems
Diploma in Clinical Medicine and
vi
Resource Centre (NHSRC) during
Surgery with one year of internship. In
2013-14 stated that the training was
Mozambique, Tecnico de Medicina
considered signicant by the 91 RHPs
Geral (TMGs) was originally trained for
covered, to serve in rural and remote
thirty-six months but this was
settings. The same textbooks were
subsequently reduced to thirty months.
used for MBBS and MLHW candidates
TMGs did not score very well on
and pharmacology training was the
assessments of physical examination
same for both courses. The cut-off
and clinical case scenarios, having
marks (60% in Assam and 75% in
faced difculty with rushed teaching
Chhattisgarh) ensured that only
and an inadequate internship.vii
students of certain merit were able to
§ The model of a three or four-year join the course.
diploma was also followed in the Indian
§ In Chhattisgarh, the doctors who
states of Chhattisgarh and Assam
trained the RMAs mentioned that

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 clinical exposure during training based curriculum of BCMP was
equipped the RMA students to identify designed to be problem-based
essential conventional treatment, and learning to acquire hands-on clinical
evaluate when they should refer skills. Three South African Universities
patients and when and when not to have produced 1, 070 qualied Clinical
prescribe antibiotics. Associates by 2018 and all of them are
§ The in-service RMAs in Chhattisgarh employed in the public sector.x
underwent a thorough examination § However, the passage of the NMC Act,
(including questions of the post- 2019 presents the opportunity to give a
graduate medical entrance test level) legal footing to a degree course for
for regular appointments in the health training MLHWs on the lines of the BSc
services. As a result, 741 RMAs were (CH) course that was already approved
regularized, which was proof of their by the Union Cabinet in 2014.
competence, acquired based on
training and subsequent eld Policy option 3: Bridge/Certificate course
experience. § Because of the urgency of responding
§ A study analysing the quality of to the rapidly increasing incidence of
prescriptions issued (for disorders NCDs by strengthening
such as diarrhoea, pneumonia, TB, comprehensive primary healthcare, the
malaria, preeclampsia and diabetes) Government of India initiated a six-
by doctors, RMAs and other health month bridge course for registered
personnel in primary health facilities in nurses (GNMs or BSc nursing
Chhattisgarh found that medical graduates) and Ayurveda doctors or
doctors and RMAs had similar average Bachelor of Ayurveda Medicine or
prescription competence scores. 61% BAMS graduates to be delivered by
of medical doctor and RMA IGNOU (Indira Gandhi National Open
prescriptions were appropriate for University). This course was launched
treating the concerned medical in May 2017.
xi
condition. § The persons trained under the bridge
course (Certicate in Community
Policy option 2: Degree course Health) were to function as MLHWs
§ South Africa launched a three year known as Community Health Ofcers
Bachelor of Clinical Medical Practice (CHOs). These CHOs were to be
(BCMP) in 2008 for training its MLHWs posted at Sub-Centres, which would
known as Clinical Associates. South then be converted into Health and
Africa followed a well- planned Wellness Centres. The objective of the
approach in launching this course; in course is to equip trainees to provide
2004, it had set up a National Task Team comprehensive primary care skills
to establish a scope of practice, training based on protocols appropriate to Sub-
curriculum, and exit outcomes for the Centre level along with managerial/
then proposed clinical associates administrative skills.
cadre. The standardized competency-
§ Experts and medical doctors interacted

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 with during GRAAM’s eld study in 1, 50,000 Health and Wellness Centres
Chhattisgarh expressed concerns operational by December 2022, it may
about the readiness of Nursing/BAMS not be viable to immediately have a
graduates trained under the six-month mandated three or four-year training for
bridge course to take up the CHOs. Nevertheless, the Government
MLHW/CHO roles in the Health and of India should plan to introduce the
Wellness Centres. One specic three to a four-year course after
concern was related to the achieving the target for the Health and
preparedness of candidates (quality Wellness Centres. Subsequently, the
concerns about nursing institutes and bridge course for training CHOs may be
their graduates). Medical doctors and withdrawn in a phased way.
experts spoke to express concerns § While there is a strong case for keeping
about the inadequate duration of a six- the clinical training aligned with certain
month course, the relative suitability of elements of the MBBS course
a three or four-year course and the (especially the pharmacology
difculty in changing the orientation or component and clinical postings), the
mindset of GNM/BSc nursing and course should not be a mere replication
BAMS graduates within six months. A of the MBBS course. Also, a degree
doctor opined that a medical provider course may possess more credibility
should possess diagnosis knowledge, and may address quality concerns
else, there could be more harm than better than a diploma course, which
help. Even in referrals for chronic NCDs bolsters the case for a degree
like diabetes (where the CHO is qualication. Furthermore, degree
expected to sort out rells of programmes provide more in-depth
medication), clinical judgement is knowledge and will potentially equip
required, without which could lead to CHOs at a higher level.
complications.
§ After 2022, the degree qualication
§ While the training course for RHPs in should be mandated for fresh
Assam included a six-month clinical recruitments of CHOs at Health and
internship and the course for RMAs in Wellness Centres. This also mandates
Chhattisgarh included a one-year for systematic engagement of the
clinical internship, the bridge course medical profession in planning the
described above, only presents an course and smoothening its future
eighteen-day clinical internship, which implementations.
may be insufcient to strengthen
clinical competencies. § The six-month bridge course, if found
necessary to be retained in future,
Therefore, there is a strong case for a three should be accompanied by the
or four-year training course compared to a following:
six-month bridge course.
1) Improved quality of nursing education
§ Keeping in mind that the Government of so that the BSc nursing graduates who
India has planned to staff its Health and take the bridge course are procient.
Wellness Centres with CHOs and make

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 The entry requirements of the course secondary care, however, the CHPs are
should be made stringent (for example required to practice under supervision.
through a national entrance test of § In Chhattisgarh, RMAs can prescribe/
clinical competencies). The curriculum practice independently for a dened list
of the BSc nursing course should also of medicines and procedures
be amended to incorporate a certain (Appendix I). In Assam, the initial
level of relevant clinical competencies legislation empowering MLHWs had
including prescribing skills. dened the list of drugs and procedures
2) Institute extensive, frequent and for RHPs. However, a court challenge
systematic in-service or refresher led to new legislation in 2015 which
training for trainees undergoing the specied the role of RHPs as assisting
bridge course who will then become doctors only.
CHOs.
Policy option 2: Supervised
C. Model of prescription § In South Africa, clinical associates were
§ The law may require non-medical envisaged not to replace medical
graduates such as MLHWs to either doctors but instead work as a team
prescribe independently or under the along with them. South Africa continues
supervision of doctors. The supervised to employ clinical associates in district
prescription may be a solution hospitals as part of a team that assists
acceptable to the medical profession doctors and nurse practitioners. The
and desirable due to the superior unavailability of medical doctors in the
training of medical doctors. However, it public sector had created serious
may be difcult to implement in practice service delivery issues, which have
as a result of the frequent non- been partially addressed by introducing
availability of doctors in health facilities primary care nurses (nurse
located in rural or remote areas. practitioners or NPs) with clear
distinctions in scope of practice and
prescribing authority between NPs and
Independent Supervised clinical associates.
§ In practice, a supervised prescription is
difcult to implement in the absence of
Model of doctors. A clear (though restricted)
prescription of scope of independent practice for
MLHW sufciently trained MLHWs should be
dened to enable them to freely perform
Fig. 3. Model of prescription of MLHWs
their roles in treating minor illnesses,
managing emergencies before referral,
Policy option 1: Independent
relling/following up for chronic
§ Section 32 of the NMC Act 2019, India
conditions, and carrying out non-
grants independent rights of
complicated deliveries and simple
prescription to CHPs as far as primary
procedures.
and preventive care is concerned. In

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§ In Chhattisgarh, MLHWs have undergone extensive eld experience of
demonstrated their competence in 12-15 years. It is recommended that
practising independently. Doctors who these cadres be recognized as having
taught at the course also believe that the completed the required qualications.
system would work as long as MLHWs All future candidates should however be
are well aware of their limitations and required to take up degree courses.
when to refer. § However, the ‘abridged MBBS’ design
for training MLHWs should also not be
Policy recommendations completely replicated. A standardized
§ The scope of the right to prescribe competency-based curriculum focused
medicines by CHPs should emanate on problem-solving and building
from the Regulations that would be hands-on clinical skills is
formulated concerning Section 32 of the recommended.
National Medical Commission Act, § The training course for MLHWs should
2019. be better tailored to the responsibilities
§ The recommended legal denition of that they would handle as CHOs at
the requirement for CHPs mentioned in Health and Wellness Centres so that
Section 32 of the NMC Act 2019 should they are well equipped to carry out their
incorporate the following: “includes responsibilities. The pharmacology
persons who have completed the component, preparation for NCD
training under any Degree Programmes screening and referral as well as the
recognized under Schedules of the management of common
Proposed Regulations.” communicable diseases should be
addressed strongly in their training.
§ There is a strong case for the four-year
Given the important role of CHOs in the
model of training MLHWs compared to
referral chain, their diagnostic
the six months bridge course which is
capabilities should be bolstered. There
being used to train CHOs for Health and
is also a need for strengthening the role
Wellness Centres, from the point of view
of CHOs in the referral mechanism.
to develop clinical competencies of
MLHWs.
Implementation considerations
§ Given the greater credibility associated
with a degree course than a diploma Education and Training: In-Service Training
course, it is recommended to train § The shorter the training of MLHWs, the
MLHWs through a degree course in the greater is the need to strengthen the in-
future. service training of MLHWs. The
§ Assam and Chhattisgarh already have additional benet of in-service training
trained MLHW cadres (trained in three would be to demystify treatment
a n d a h a l f y e a r o r f o u r- y e a r pathways and keep the skills of the
programmes) who have also MLHWs updated.

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A. Comprehensive and development of standard treatment
guidelines or protocols for a variety of
customized refresher
illnesses.
training model
§ Chhattisgarh had designed a ten-day B. Algorithms, protocols and
refresher training on primary health care guidelines and training to
management for all its RMAs who were
explain them
trained under the PMHM course. All 1,
200 RMAs received this one-off training § Algorithms, protocols and guidelines
on primary health care management at for screening, treatment and drug
the reputed medical institute, CMC titration are very important to simplify
Vellore in batches between 2011 and prescription for non-medical
2016. At this course, the RMAs also prescribers. However, the better uptake
obtained a better understanding on how of protocols may be facilitated by well-
to treat patients using rst-generation designed training programmes used to
and second-generation antibiotics. explain them.

§ Apart from the CMC Vellore training,

The PALM PLUS Training Initiative for
other refresher pieces of training were
Nurses and MLHWs in Malawi
also conducted for RMAs. These
i n c l u d e d a f o u r- d a y t r a i n i n g t o In Malawi, a training initiative known as
PALM PLUS was conducted which had 8-
strengthen RMAs’ skills to handle
12 training sessions over a three-to-four
Health and Wellness Centres, a six-day
month period. The training included small
training on paediatric care at AIIMS
group in-service and on-site sessions
Raipur, and 15 days training on using case-based pedagogy, facilitated
maternal health at the State Institute of by a trusted peer. The training allowed
Health and Family Welfare (SIHFW), healthcare workers to grasp the
R a i p u r. Va r i o u s o t h e r t r a i n i n g guidelines for proper diagnosis and
programmes at the district and state management of HIV and certain other
level under the National Health communicable disorders.
Programmes have also been All PALM PLUS trainees who completed at
conducted. These training programmes least six educational outreach sessions
have not only helped in motivating the were issued a certicate and awarded
RMAs, but have also helped enhance continuing professional development
their skills in a more structured and (CPD) credits with the Malawi College of
comprehensive way. Nursing or the Malawi Medical Council.
The linkage of CPD credits reinforced the
§ There is a need for customized and in- uptake of the educational outreach
depth refresher training of MLHWs, on session. Although PALM PLUS guidelines
the lines of the approach followed in are simple and self-explanatory, PALM
Chhattisgarh and other innovative PLUS included an instructional
approaches, such as the use of programme on how to use the guidelines,
distance learning platforms. Alongside, since “the impact of passive guideline
xi
importance should be given to the dissemination on practice” is minimal.”

| 9 |
The Malawi case presented in the text box Gentamicin, Metronidazole and
above highlights the importance of not only Amoxicillin. Gentamicin, Metronidazole
explaining guidelines through suitably and Amoxicillin are categorised as the
designed training sessions but also on access group of antibiotics in the WHO
improving the uptake of such sessions 21st Essential Medicines List in 2019.
through incentives such as CPD credits. Ciprooxacin, a uoroquinolone is
however categorised under the Watch
Medicines that can be prescribed Category due to its increased potential
for resistance. Replacing Ciprooxacin
§ The rules for Section 32 of the NMC Act
with one of the access group of
would need to specify the medicines
antibiotics, Ampicillin, Benzylpenicillin,
that MLHWs can prescribe.
or Amoxicillin + Clavulanic Acid should
§ In Assam, RHPs deployed in Sub- be considered.
Centres can only select medicines from
§ While the list under the Ayushman
the Assam Essential Medicines List
Bharat Yojana is a good reference point,
(EML) reserved for SC level. Interviewed
it does not include medicines required
RHPs felt that the medicine list was not
for other National Health Programmes
sufcient, since even common
such as National Vector Borne Disease
medicines like antacids and cough
Control Programme or Revised National
syrups were not covered by this list
Tuberculosis Control Programme
which had only 31 medicines. They also
(RNTCP). Clarifying the list in
felt that they were trained to prescribe a
accordance with all national
larger range of medicines.
programmes is desirable.
§ Chhattisgarh's 2019 EML has listed 43
§ The medicine lists to be dened should
medicines in the universal list which
also be aligned with local morbidity and
reaches up to the Sub-Centre level. 157
mortality data, and based on Standard
medicines have been listed in the
Treatment Guidelines for the MLHWs.
Primary Health Centre list where the
Striking a balance between the
RMAs mostly practice.
imperatives of drug safety, attending to
§ The need for enhancing patient commonly seen health problems, the
awareness is evident from both the training of MLHPs and the availability of
Assam and Chhattisgarh case studies diagnostic facilities are important.
since patients pressurize the MLHWs to
prescribe medicines that are either not Stakeholder consultation
available in the EML or are beyond the
competency of the MLHW. § The sustainability of the implementation
of MLHW prescription depends on the
§ The Ayushman Bharat Operational support of key stakeholders, which
Guidelines for Health and Wellness includes the medical profession.
Centres (HWCs) denes a much larger
list with 91 medicines that should be § In both Assam and Chhattisgarh, the
made available at the HWCs.xii These system was adopted without the
include the antibiotics Ciprooxacin, systematic engagement of the medical

| 10 |
 profession. The MLHW systems in both § Restrictive medicine lists may hamper
states faced prolonged legal battles the role of MLHWs in treatment
from the Indian Medical Association as processes. The Ayushman Bharat’s
a consequence, and the training course medicine list for Health and Wellness
had to be discontinued in both states.xiii Centres is a good reference for the
§ In South Africa, the clinical associate preparation of medicine lists for MLHWs
system was consciously planned and (with some changes such as dropping
eshed out for four years before it was of ‘Watch’ categories of antibiotics and
launched. buy-in from the medical addition of drugs from the National
profession for the clinical associate Programmes), provided that the
system was obtained partly by the required laboratory and refrigeration
involvement of doctors in preparing the facilities are in place.
curriculum. Committed and technical § Pharmacovigilance and rational use of
expert family physicians were carefully antibiotics should be well addressed in
selected to support decision-makers in the training of CHOs. Training MLHWs
the government. These physicians on the concept and utilising the Access,
participated in reviewing international Watch and Reserve classication
evidence, making country visits, (AWaRe) categorisation of antibiotics is
delineating the scope of practice for recommended.
MLHWs at the district hospital level and § There is a need for MLHWs to be well
developing the national curricular trained in protocols for management
framework. and referral of NCDs as well as
§ The sudden introduction of communicable diseases like malaria.
transformational systems such as Such protocols (for example those
MLHW prescription is not conducive to based on the National Vector Borne
gain support from stakeholders such as Disease Control Programme) should be
the medical profession. The key is to disseminated amongst the MLHWs and
engage inuential or reputed doctors in the application of the protocols should
dialogue and planning over a longer be lucidly explained through
period; such doctors in turn can help appropriate training programmes.
develop support to the idea among their § There is a need for evidence-based
networks. advocacy and extensive stakeholder
consultation with representatives of the
Implementation suggestions medical profession over a long period to
§ The comprehensive refresher training dismiss their misconceptions and fears
design in Chhattisgarh for RMAs is concerning the MLHW system. There
worth emulating from the points of view should be an outreach to all
of capacity building and also the professional associations of doctors.
motivation of MLHWs, instead of relying The South Africa case afrms the
only on piecemeal refresher training signicance of involving doctors in the
under the national programmes. planning of the MLHW systems and
curriculum.

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Select references quinine, primaquine, sulfadoxine-
§ Doherty J, Couper I, Fonn S. (2012). Will pyrimethamide
clinical associates be effective for South • Antileprosy - dapsone, rifampicin,
Africa?. South African Medical Journal, colfazimine
102 (11): 833-835. Retrieved From: • Anti-amoebic - metronidazole,
http://www.samj.org.za/index.php/sam tinidazole, dooloxanide furoate
j/article/view/5960/4758
• Anitiscabies - benzyl-benzoate,
§ NHSRC. (2014). Rural Health gamma benzene hexachloride
Practitioners augmenting sub-centre
service delivery in Assam Retrieved • Topical antifungal
From: • Antiviral
http://nhsrcindia.org/sites/default/les/ • Anticholinergic Dicyclomine
Rural%20Health%20Practitioners%20- • Antiemetics
%20Augmenting%20Sub%20Center%
20Service%20delivery%20in%20Assa • Antipyretics and analgesics
m.pdf • Laxatives
§ Rao, K.D. et al. (2013) which doctor for • Oral rehydration solutions
primary health care? Quality of care and • Hematinics and vitamins
non-physician clinicians in India. Social
Science and Medicine, 84. • Bronchodilators - Salbutamol,
theophylline, aminophylline
§ Appendix I: Scope of Practice of RMAs
in Chhattisgarh • Expectorants

§ Prescription: Drugs that can be • Oral contraceptives

prescribed by an RMA (as per Govt • Gentian violet 1% solution
Order dated 19.06.08) • Miconazole 1% cream
• Antacids, H2 Receptor Blockers, • Vitamin A liquid
proton pump inhibitors,
Antihistaminic • Vitamin B Complex

• Antibiotics - Cotrimoxazole, • Folic Acid Tab

Trimethoprim, Noroxacin, • Xylocaine local
quinolones, Tetracycline, • Methylergometrine tablets
Gentamycin, Cephalosporin,
Erythromycin, Nitrofurantoin, • Methylergometrine injections (for
Metronidazole, Tinidazole, PPH)
Ampicillin § Certain emergency drugs can be given
• DID Antitubercular - INH, before referral, Referral of all sick
rifampicin, ethambutol, patients after initial management
pyrazinamide, Anthelmintics- § Surger y : Operative procedures
mebendazole, albendazole permitted to be carried out by a Rural
• Anitimalarials - chloroquine, Medical Assistant (as per Govt Order
dated 19.06.08):

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§ Repair of small wounds by stitching, 5-7 days: only if the improvement is
drainage of an abscess, burn dressing, visible in the condition of the patient
and applications of splints in fracture or else they should refer the patient
cases, application of tourniquet in case to a nearby CHC for further
of a severe bleeding wound in a limb treatment
injury • Follow up treatment of diseases
§ C o n d u c t i o n o f d e l i v e r y, b a s i c initiated by medical Ofcers of CHC
management of complications of and PHC
pregnancy and childbirth, suturing of
1st-degree Perineal tears Contributors and
§ Other tasks: Other procedures/tasks acknowledgements
(Govt. order dated 19.06.08)
This policy brief is the outcome of a multi-
§ Follow up of all National Health pronged and comprehensive study that
Programmes in Coordination with Block GRAAM has carried out in partnership with
Medical Ofcer WHO, to generate evidence for policy
§ Linkage with communities to increase makers to consider introducing regulated
service delivery MLHW and Nurse prescription.

§ Regular meeting with peripheral health GRAAM team WHO team

staff
Ananya Samajdar Hilde De Graeve
§ Procedures not to be performed (Govt
R Balasubramaniam Tomas Zapata
order dated 19.06.08)
Sunitha Srinivas James Buchan
• Medicolegal cases
Shubhangi Singh Dilip Mairembam
• Post-mortem
Jamila Emily Daniel
§ Other elements of the scope of work:
• Provide primary level treatment for

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End Notes training Primary Health Practitioners. In 2015, before
i
the Delhi High Court, the Additional Solicitor General of
The recommended policy solution for each thematic India stated that the graduates of the BSc (CH) course
component in this brief is either one of the policy would be an integral part of the health care system and
options presented or a combination of elements from would support the health workforce at appropriate
multiple policy options presented. levels. However, he admitted that there was no Central
ii
World Health Organization. (2018). Mid-level health Act which provides for the rights, duties and privileges
workers: a review of the evidence. of such proposed graduates. In its decision on 2nd
iii
September 2015, the Delhi High Court ruled that once
In this brief, we consider graduate nurses/Registered
the Central Government has undertaken to introduce
nurses as being outside the purview of the category of
the B.Sc. (Community Health) course, it must give the
MLHWs, unless where trained nurses themselves
course a rm legal footing and introduce it in
undergo to become clinicians performing functions
institutions and universities run by the Central
similar to doctors (for e.g. nurses who take up the
Government and also provide help to the State
bridge course to become CHOs at Health and
Governments to introduce the same. It must be noted
Wellness Centres). Nurse practitioners who undergo
that the obstacle of there being no central act or legal
more prolonged training are also excluded from this
footing was subsequently remedied through the NMC
denition.
Act, 2019. The regulations for the NMC act need to be
iv
The Operational Guidelines for Health and Wellness dened in a way that would legitimize a degree course
Centres (issued in 2018 by the Govt of India) clearly for training the MLHW cadres.
dene that for chronic diseases, CHOs at Health and vi
Couper, I et al.. (2018). Curriculum and training needs
Wellness Centres would need to provide medicines
of mid-level health workers in Africa: a situational
under standing orders of Medical Doctors. However
review from Kenya, Nigeria, South Africa and Uganda.
such clarity is not provided with respect to providing
BMC health services research, 18(1), 553.
medicines for other/non-chronic illnesses. Also, CHOs
vi
are allowed by the operational guidelines to provide iFeldacker, C. et al. (2014). Mid-level healthcare
medicines under the very limited medicine list personnel training: an evaluation of the revised,
contained in Item 23, Schedule K of the Drugs and nationally-standardized, pre-service curriculum for
Cosmetics Act (which puts CHOs on the same footing clinical ofcers in Mozambique. PloS one, 9(7),
as the much lesser trained community health e102588.
volunteers and multipurpose health workers ). vii
iMBBS (Bachelor of Medicine and Bachelor of
Furthermore, the scope of practice of CHOs also Surgery) is India’s undergraduate course which
needs to be re-examined and redened in the context creates qualied medical doctors.
of Section 32 of the NMC Act, which was passed after
ix
the Operational Guidelines for Health and Wellness Rao, K.D. et al. (2013) Which doctor for primary health
Centres were issued. care? Quality of care and non-physician clinicians in
v
India. Social Science and Medicine, 84.
The Union Cabinet of India had approved the
x
introduction of a course namely, Bachelor of Science Ngcobo S. (2019), Clinical associates in South Africa.
(Community Health) of BSc (CH). Though the 109 (10): 706. Retrieved From:
proposal for B. Sc. (CH) had been prepared in https://www.researchgate.net/publication/336215991
consultation with (the then) Medical Council of India, _Clinical_associates_in_South_Africa/link/5d949ef99
Indian Medical Association had opposed the proposal 2851c33e94fe58a/download
for the course. Though the Parliamentary Standing
Committee on Health and Family Welfare had also xiSodhi, S., et al. (2014). Supporting middle-cadre
recommended not to introduce B.Sc. (CH) course, the health care workers in Malawi: lessons learned during
Ministry of Health and Family Welfare did not accept implementation of the PALM PLUS package. BMC
the recommendation, and sought the approval of the health services research, 14(1), S8.
Cabinet; the Union Cabinet subsequently approved xii
NHSRC. (2018). Ayushman Bharat Comprehensive
the proposal, after which the press notication for the Primary Health Care through Health and Wellness
course was issued in February 2014. In its press Centres - Operational Guidelines.
release, the Government of India declared that the xiii
A recent judgement of the High Court of Chhattisgarh
course is not mandatory and will be introduced only in
(in Feb 2020) has recognized the four year PMHM
States that wish to adopt it.
course for training MLHWs as legally valid. The
Meanwhile the Delhi High Court was looking into the judgement comes after a 20 year legal battle.
matter of the non-implementation of a course for

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The policy brief outlines policy options, recommendations and implementation suggestions to operationalise mid-
level health workers’ (MLHWs) prescription in India. Such an initiative is also an opportunity to strengthen workforce
response in providing primary health care in pandemic situations such as COVID-19 and during other epidemics.