Resolving the Paramedical Staff Shortage in India: What are the Options?

By Arunima Rajan

How can we strengthen and future-proof India's paramedical workforce?

A report commissioned by the Ministry of Health and Family Welfare (MOHFW) indicates the demand for Allied Health Professionals in India (excluding rehabilitative professionals) is ~4,700,000, while availability is in the range of ~800,000-1,100,000.

AHPs deliver expert healthcare services to therapeutic, diagnostic, curative, preventive and rehabilitative interventions. The provision of health care is increasingly becoming interdisciplinary, which calls for reduced dependency on the doctor, who is just one part of this team. The obsession with the conventional (doctor-centric) approach to healthcare delivery needs to be changed. Instead, skilled AHPs could step in to provide comprehensive services to the patients, leading to better patient outcomes and reducing the burden and dependency on tertiary care hospitals. Thus, reducing the cost of treatment and out-of-pocket expenditure on healthcare.

Upskilling Healthcare Workforce and Faculty

As many experts point out, increasing the number and quality of training programmes is the solution to the problem. The creation of more opportunities will ensure the retention of paramedical staff.

Most private colleges are managed with inadequate infrastructure and staff, resulting in graduates without the relevant knowledge and expertise required to be employed in hospitals and healthcare organisations.

In 2012, a study by the Public Health Foundation of India reported that the country needs at least 2.04 million dental staff, 1.8 million rehabilitation specialists, 850,000 anaesthetists, 230,000 medical technology workers, 127,000 ophthalmologists and optometrists, 61,000 medical lab technicians, 19,000 radiographers, and 7,400 audiology and speech-language specialists to fill the gap.

Dr. Arjun Kalyanpur, Chief Radiologist and CEO of Teleradiology Solutions, points out that the shortage is primarily related to the lack of training programmes in the space. "Emigration to other countries is another cause of the deficit," he adds.

Dr. Kalyanpur notes that there will be an increased demand for a paramedical workforce soon. "Medical Imaging technologists are beginning to play an increasingly important role in the radiology space worldwide. In the UK, radiographers have been seen to add value to mammography and emergency imaging, where they provide valuable support for the reporting radiologist. In our organisation, we have piloted a work module where medical imaging technologists who have been provided focused training perform peer review to supplement radiology reporting and enhance report quality. In our RXDX clinics, nurse assistants provide valuable support to nurses during busy times. Such initiatives boost the utilisation and demand for paramedical staff," he explains.

Strengthening Healthcare Training Infrastructure

The lack of qualified paramedical personnel considerably impacts the Indian healthcare business.

Dr. B. Unnikrishnan, the Dean of Kasturba Medical College, Mangalore, says, "While we have institutions imparting allied health courses in the country, the sector is unregulated. The most critical issue is hospitals' lack of practical and clinical training. There are very few institutions in the country offering quality education and training for aspiring allied health professionals," he says.

He continues: "The commissioning of the National Commission for Allied and Healthcare Profession Act 2021, by the gazette notification of the Parliament, has been a watershed moment for this sector, and this has paved the way for introducing standardised delivery of allied health education in the country. Since it is a very skill-intensive course, the training at the hospital, like in the case of doctors and nurses, should be the priority. As mentioned above, most institutions offering the programs are not attached to hospitals, thereby lacking the quality and required skills."

The shortage of competent paramedical professionals significantly impacts the healthcare industry in India.

There is a lack of regulation in the allied health education sector providing training. This is being addressed by current initiatives like forming the council and commission to regulate the training of professionals, standardising the curriculum and registration of professionals.

The paramedical workforce shortage is a much larger issue that needs to be tackled with effective long-term solutions. "The poaching of skilled workforce by a strong competitive private health care industry could pose a challenge to the already strained public healthcare infrastructure. In addition, there is a huge demand for a skilled workforce in the GCC countries and the US and UK, where allied health professionals constitute 60% of the total strength healthcare professionals. The remuneration is on par with other highly paid and other highly skilled professionals," adds Unnikrishnan.

Lack of Credible Programmes

Source: KPMG Report

How can we strengthen and future-proof the paramedical workforce?

Historically, there has been no Human Resources planning in Indian healthcare. Traditionally, health workforce had been confined to doctors and nurses, giving little or no importance to allied health and paramedical staff. Also, there was no proper regulatory mechanism until recently, which resulted in a lack of a structured curriculum framework for paramedical training. Another reason for the shortage is the migration of paramedical work to other countries because of poor pay packages in India.

Dr. Feroz Iqbal is an Associate Professor at the Tata Institute of Social Sciences, Mumbai. He points out that the shortage has severely affected healthcare delivery because doctors and nurses may have to perform tasks that generally would have been handled by paramedical workers. Working of departments has been hampered by shortages. For example, the inability to employ nuclear medicine technologists has restricted the functioning of the department.

South Indian states and Western India have a high number of paramedical personnel due to the presence of a large number of institutions in these regions. There is a correlation between medical schools and the availability of paramedical staff. Many of the best medical schools also offer paramedical programmes. For instance, Manipal University and CMC Vellore are two colleges that produce qualified paramedical and allied health professionals. Similarly, public institutions such as AIIMS in New Delhi and PGI in Chandigarh offer paramedical programmes that produce high-quality paramedics.

"It is necessary to elevate the dignity of paramedical personnel. Frequently, they are not recognised for their labour and are seen as second-tier employees. Frequently, paramedical courses are categorised as ‘vocational courses’ rather than ‘professional courses.’ There is relatively limited opportunity for paramedics to practise independently. Second, the government must increase the number of paramedical positions in government facilities," explains Dr. Iqbal.

In the delivery of healthcare, several disruptive innovations are taking place. "This could lead to a decline in the need for some paramedics, while demand for new paramedics may increase due to new technology. Some of the currently offered paramedical courses will still be in demand.

For instance, "beating heart surgery" might make perfusionists less critical. Emergency medical technicians are another specialised field where there is a need for more paramedics." he adds.

Although in tier I cities, the waiting times to see a specialist for those who can afford private healthcare may not be high, we shouldn't confuse access to doctors with the functionality of the healthcare system. There are countless delays and inefficiencies because of the lack of access to diagnostic care (like scans and biopsies) and rehabilitative care. "In addition to quality issues, when there is a shortage of these professionals, in many institutions, junior doctors are expected to fill some of these gaps, compromising their quality of training and the final healthcare delivery to the patient," says Narayana Subramaniam, Head of Department, Head and Neck Oncology, Shri Shankara Cancer Hospital and Research Centre.

High-quality training courses for paramedical workers is the way forward- they can help administer quality care under doctors' direct or remote supervision. Along with expanding medical training through medical colleges, if paramedical training isn't scaled proportionately, the on-ground ability to deliver care will be limited. There also needs to be a clear framework under which these professionals practice and are licensed so there of no ambiguity concerning their role in healthcare delivery and a clear career progression for them.

"In oncology especially, rehabilitative care is underdeveloped in many parts of the country. Cure without rehabilitation is a disservice to the patients. Because of the enormous shortage of oncologists, there should be an expanded role for paramedical professionals who are adequately trained to screen for cancer, administer routine follow-up care and rehabilitation, offer palliative and end-of-life care and grief counselling," concludes Subramaniam.

The shortage of allied healthcare professionals in India is a significant concern for patients and providers. If left unaddressed, it could severely hamper the country's ability to provide quality care for its growing population. To solve this problem, it will be critical for policymakers to invest in quality training and education programmes that can attract and retain skilled workers in the country. Additionally, efforts must be made to stem the tide of brain drain by providing incentives for Indian workers to stay put instead of seeking opportunities abroad. Only then will India be able to meet the challenges posed by its ageing population and ensure that everyone has access to quality healthcare.