Nurse Practitioners-India’s Answer to Addressing Access to Healthcare

Lipika Nanda1* and Eunice Lobo2

Bhubaneswar, India, Email: lnanda@iiphb.org

Opinion

Many developing countries are facing serious workforce challenges in the health sector, especially with respect to physician availability [1]. This has been affecting service provision, if health services in these countries are primarily provided by the physicians. Developed countries have, over the past several years, succeeded in demystifying medical management of patient care and have introduced non-physician practitioners, mainly nurse practitioners to become primary care providers within health systems. The primary care within the National Health Services (NHS) system in UK is heavily dependent on nurse practitioners as care givers, since the 1980s. Similarly, nurse practitioners have been providing a triaging role in primary care service within the USA health systems since the 1960s, Australia since 1990s and the Netherlands since 2010, with the inclusion of advanced nurse practitioners and physician assistants as well [2].

The Indian health care sector needs are growing at a continuous pace, with increasing population size, dual burden of diseases due to rise in chronic and life style diseases, emerging and re-emerging diseases to name a few [3, 4]. Hence a dire need for reorganization and decentralization of health care services by task shifting approach is requisite to address the increasing demand of the health care sector [5].

Nurses are the backbone of any health care system, and are known for selflessly working round the clock with compassion and care. The recent exemplary service by the young nurse, Lini Puthussery, who died of Nipah virus infection in Kerala resonates with the challenging nature of the caregiver’s job [6]. In India, this vital and crucial Opinion cadre forms two-thirds of the health workforce, with the nurses’ ratio in urban to rural standing at 4:1 according to the World Health Organisation [7, 8]. However large number of nurses, though educated in India have been known to take up employment opportunities in the Middle East and Western countries. Reasons for this perhaps could be attributed to low remuneration packages, sub-standard working conditions especially in the public sector, no continued education or skill development, and as mentioned earlier high patient load in rural areas [9]. Additionally, though nurses have exhibited competence in leadership required for strengthening of health care in various other country, lack of opportunities or representation in India causes discouragement. The strong opposition by doctors opposing inclusion of nurses in the Medical Termination of Pregnancy (Amendment) Bill in 2014 reflects the attitude towards the nursing cadre [10, 11]. However, evidences across the globe highlight the benefits gained through the advancement of nursing cadre through nurse practitioners degree. Systematic review and meta- analysis point out the similarity in quality of health care services in overall clinical care and health outcomes provided by nurse practitioners and general practitioners, especially in at the primary care level. These include drug prescription and screening tests that are advised on discretion by nurses due to the extensive training modules on pharmacology and pathophysiology, and disease management [12]. Further trials and systematic reviews alike have reported increasing numbers of patients approaching nurse practitioners as the first point of care, along with higher satisfaction linked to longer consultations with nurse practitioners than general practitioners, and lower costs of consultation by 12.5%

[13, 14, 15]. The recent Brooke institution report published in June 2018, also showed how health reform could help improve access and keep costs down without decreasing quality of care [16].

Recognizing the imperative need for at establishing nurse practitioners in India, several attempts have been made in the past. The Government of West Bengal introduced nurse practitioners in midwifery (NPM) by providing additional training to diploma and graduate nurses in public service as early as 2005. However, were unable to obtain due recognition until 2010.Following the lead, Gujarat government initiated a post basic diploma on nurse practitioner in midwifery since 2009 [17]. Similar steps of training registered nurses in NPM by the state governments of Telangana and Kerala, along with nursing council of India has been initiated over the past years [18, 19, 20]. JHPIEGO - working in India for almost a decade with the public-private sector in maternal and newborn health has been advocating the engagement of nurse practitioners in management of public health programmes [21].

Therefore, taking notice more recently government initiatives have been directed towards exploring opportunities for enhancing productivity. The recent National Health Policy included establishing cadres like Nurse Practitioners and Public Health Nurses [22]. Consequently, Shri JP Nadda, Union Minister for Health and Family Welfare launched two new Nurse Practitioner Courses in 2016. Moving beyond midwifery, a two-year residential masters in science programme in Critical care, and a one-year diploma in Primary healthcare invited applications from registered nurses across the country. These courses will provide autonomy to nurses along with increased responsibility and accountability while focusing on their collaborative roles in public health [23].

India is embarking and will be on several reforms in the health care sector both at all levels making it imperative for having nurse practitioners have an active role both at the primary as well as the hospital care level, both secondary and tertiary levels. They will have an enabling role in making the Health and Wellness Centers operational while a huge role in the roll out of Ayushman Bharat [24]. Taking lessons from other developed countries, it will also be important for the nurse practitioner to have a public health leadership role in a country like India. This will be explored further through the National Medical Commission Bill that intends to authorize nurse practitioners to perform an active role towards improving the Indian health care sector [25].