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Task-shifting challenges for provision of

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 International Health Advance Access published August 4, 2014

Int Health
doi:10.1093/inthealth/ihu048

ORIGINAL ARTICLE
Task-shifting challenges for provision of skilled birth attendance:
a qualitative exploration
Nomita Chandhioka,*, Neelam Joglekarb, Aparna Shrotric, Panna Choudhuryd, Nayanjeet Chaudhurye,1
and Shalini Singha

a
Division of Reproductive and Child Health, Indian Council of Medical Research, P.O. Box No. 4911, Ansari Nagar, New Delhi 110029, India;
b
Consultant, Qualitative Data Analyst, Pune 411030, Maharashtra, India; cConsultant, Obstetrics and Gynecology, Pune 411004,
Maharashtra, India; dConsultant, Pediatrics, New Delhi 110023, India; eAsian Institute of Public Health, Bhubaneswar 751002, Orissa, India
1
Present address: Director, Research, Population Services International, C-445, Chittaranjan Park, New Delhi 110019, India.

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*Corresponding author: Tel: +91 11 26589493; Fax: +91 11 2658 8755; E-mail: n_chandhiok@hotmail.com

Received 24 February 2014; revised 6 June 2014; accepted 9 June 2014

Background: Shortage of skilled birth attendants (SBA) is one of the determinants of maternal mortality in India.
To combat this shortage, innovative task-shifting strategies to engage providers of the Indian system of medicine
(Ayurveda and Homeopathy), called AYUSH practitioners (AP), to provide SBA services is being implemented.
Methods: Engagement of APs for SBA service provision was assessed in 3 states of India (Maharashtra, Rajasthan
and Odisha) through 73 in-depth interviews (37 with APs and 36 with programme managers). The interviews
explored the providers SBA training experience, barriers for SBA service provision, workplace and community ac-
ceptance, and the perspective of programme managers on the competence and quality of SBA services provided.
Results: SBA training led to skill enhancement with adoption of appropriate maternal and newborn care prac-
tices. A dedicated trainer, more hands-on practice, and strengthening training on newborn care practices and
management of complications emerged as the training needs. Conditional involvement in SBA-related work, a
discriminatory attitude at the workplace and lack of legal/regulatory authorisation were identified as barriers
to the inclusion of APs in SBA service provision.
Conclusion: Quality skill enhancement measures, an enabling work environment, a systematic task-shifting
process, role definition, supportive supervision and credentialing could be key for the integration of APs and
their acceptance in the health system.

Keywords: Credentialing, Integration, Skilled birth attendant, Supportive supervision, Task shifting

Introduction women and newborns.6 However, a shortage in health providers,

Institutional delivery with skilled birth attendance is the corner-
stone of Indias efforts to reduce maternal and infant mortality
and to achieve its National and Millennium Development Goals.1
In India, an inverse relationship between distribution of trained
birth attendants and maternal mortality ratios has been demon-
strated.2 The National Rural Health Mission (NRHM) was launched
in 2005 and introduced new schemes such as the Janani Suraksha
Yojana that incentivise institutional delivery along with free refer-
ral linkages.3 This has led to an overall increase in facility-based
deliveries from 41%4 to 60.5%.5 Concomitant to the thrust on
institutional deliveries was the need to equip institutions with
skilled birth attendants (SBA) trained in skills to manage normal
pregnancy, delivery and postnatal care, and to identify, manage
or refer presenting complications in pregnant or postpartum
especially in rural areas, impedes this effort.7 In India, 52.7% of
births are attended by a SBA, with this proportion being lower in
rural areas (43.6%).8 With current fertility rates, national births
that are not attended by a skilled health worker are expected to
reach 69 million between 2011 and 2015,9 with an estimated
workforce shortage of 25 620 to attain 90% skilled birth attend-
ance by 2015. The WHO recommends closing existing gaps in
health coverage and improving maternal and newborn health
outcomes by active human resource policy interventions in coun-
tries facing a shortage of human resources.10 One of the key inter-
ventions could be optimising the potential of the existing health
workforce by effective task shifting for improving access and
cost effectiveness within health systems.
India has the advantage of having a large number of doctors
of the traditional Indian system of medicine11 belonging to

# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved.
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1 of 9
N. Chandhiok et al.
Ayurveda, Yoga, Unani, Siddha and Homoeopathy and collectively
termed AYUSH, who have a major presence and good acceptabil-
ity in rural areas. The Ayurveda and Homeopathy stream of medi-
cine has a well-defined graduate course and clinical training that
is equivalent in duration to that of the MBBS degree.12 The curric-
ulum includes the theory of basic obstetrics and gynaecology,
including the conduct of normal labour and related activities.
Innovative strategies of task shifting are being explored to meet
the shortfall of SBAs and, in line with WHO recommendations,
the lack of available manpower could be combated by meaningful
phased integration of providers from Indian systems of medicines,
i.e., AYUSH practitioners (AP), with those of the modern system of
medicine. Mainstreaming and task shifting of APs is recommended
to fill the gap of shortage of skilled and qualified health workers by
Indian public health professionals and researchers.13 Under the
initiative of the NRHM, 11 478 AYUSH doctors and 4894 AYUSH
paramedics have been appointed on a contract basis at peripheral
health centres throughout India.14 In many states, APs are being
provided competency-based SBA/BEmOC (basic emergency obstet-
ric care) training similar to that provided to practitioners of the
modern system of medicine so that they can conduct deliveries
in centres crippled with a shortage of regular staff.
To facilitate smooth mainstreaming of APs, the process needs
to be evaluated and barriers need to be minimised. We conducted
a mixed methods study with a hypothesis that APs, specifically
those belonging to the Ayurveda and Homeopathy stream of
medicine, can effectively provide SBA services under the Repro-
ductive and Child Health Programme of the Government of
India. As part of this study, from the qualitative data collected,
we also assessed the barriers/challenges faced by APs providing
SBA services in the public health sector in selected states as
well as their training needs. This paper presents the results on
the barriers/challenges to successful implementation of task
shifting and would be helpful to policy-makers for strategising
capacity building of APs and identifying opportunities for providing
an enabling environment.
Materials and methods
The Indian Council of Medical Research (ICMR) carried out a multi-
site mixed-methods study in two districts each of three states
(Maharashtra, Rajasthan and Odisha) in India. The districts were
selected purposively after discussion with the state health author-
ities and were those where maximum numbers of APs were SBA
trained, deployed at primary healthcare settings and conducting
deliveries. As one of the objectives of the study was to observe
the intrapartum care provided by APs, five to six health facilities,
with the highest number of deliveries conducted by APs in the
last 3 months, were selected purposively from each district by
an ICMR core committee.
The state NRHM and the district health authorities facilitated
implementation of the study. Prior to initiation of the study, a
project sensitisation meeting was organised in the state capital,
and state- and district-level AYUSH and health officials were
invited to attend. They were informed about the significance of
the project, its procedure and outcome. Their support was
requested for the smooth conduct of the study along with neces-
sary directions to the district AYUSH/health officials to co-operate
and participate in the study.
2 of 9
Data collection was initiated in 2011 after obtaining necessary
technical and ethical approvals. Trained consultants who were
experienced medical professionals in the field of maternal and child
health carried out the data collection. The qualitative component of
the study comprised in-depth interviews with programme man-
agers (n36) and APs (n37), selected purposively. APs selected
were those who had received SBA training and were conducting de-
liveries at peripheral heath centres. The programme mangers
included SBA trainers (6), state-level supervisors (5), district-level
supervisors (20) and medical officers who were in-charge of health
facilities (4). Results from the in-depth interviews are presented in
this manuscript. An in-depth interview guide was used to conduct
the interviews. The guide included four themes: roles and responsi-
bilities; capacity building; challenges and barriers to provide SBA
services; and acceptance by community and colleagues. The
guide was developed through a consultative process that included
the study investigators, policy-makers and study consultants. The
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guides were pilot tested in the field. The pilot interviews were used
to modify and finalise the interview guides. After obtaining neces-
sary informed consent from the potential respondents, the inter-
views were conducted in a confidential environment and in the
local language. They were tape-recorded, transcribed and trans-
lated by the study consultants. The interviews were entered into
Microsoft Word (Microsoft Corp., Redmond, WA, USA) and data ana-
lysis was carried out by a consultant behavioural scientist, trained
and experienced in community health research. Data analysis
was done using QSR N6 software (QSR International, Melbourne,
Australia) for qualitative data analysis. The Microsoft Word files
were converted into text files and transferred to the software.
The primary objective of the present analysis was to identify the
barriers/challenges to engagement of APs in providing SBA services.
The interviews were read repeatedly to generate the inductive
codes. These primary codes were then pooled together into
broader categories, namely roles and responsibilities of APs, acquir-
ing new skills by the APs, use of the skills, benefits and barriers/chal-
lenges for application of SBA skills, and suggestions for improved
integration of APs. Codes on views and perceptions of programme
managers regarding the capability of APs to provide SBA services
and their integration in SBA service provision were also generated
from the data. The coding scheme was finalised through a con-
sultative process with study investigators and consultants involved
in data collection. The codes were created in the software. The
textual data obtained from the interviews were put under appropri-
ate codes. The data compiled under different codes from interviews
with APs and programme managers were read and compared to
establish triangulation within the two categories of the respon-
dents. SBA training gaps and needs were identified from the data
coded into skill enhancement and application of the SBA skills
and the roles and responsibilities of APs at the health facilities.
The data on views and perceptions was interpreted to arrive at
barriers/challenges for successful integration of APs in SBA service
delivery. The recommendations for better integration using an
effective task-shifting mechanism were drawn from this analysis.
Results
A total of 73 interviews (37 APs and 36 programme managers)
were conducted in the three states. Data from 71 interviews are
presented here as 2 interviews could not be processed because
of technical difficulties in data transcription.
International Health

Study settings Factors affecting integration of AYUSH practitioners

The three states, besides being situated in geographically diverse
parts of the country (North, Rajasthan; East, Odisha; West, Maha-
rashtra) also differed when key health indicators such as total fer-
tility rate, infant mortality rate and maternal mortality ratio were
considered. Maharashtra is a better performing state, with levels
of these indicators being much lower than the national average.
Both Rajasthan and Odisha are socio-economically disadvan-
taged states, referred to as empowered action group states, and
levels of health indicators in both the states are higher than the
national average.15 The strategy of deployment of Ayurvedic and
Homeopathic practitioners for the delivery of primary healthcare
has been in place in Rajasthan and Odisha for only 3 years but
for over a decade in Maharashtra. Under the NRHM, 426, 1042
and 1283 APs have been appointed in Maharashtra, Rajasthan
and Odisha, respectively.16 APs are posted at First Referral Units,
in skilled birth attendance services
SBA training is an important step to prepare and empower APs
for integration in SBA services. We analysed how the training
helped APs to empower themselves to provide appropriate SBA
services. During this process, we assessed the reports of APs on
their integration into the system, their perception of how the com-
munity accepts them as a provider, whether the health facilities
provide them an enabling environment and what are the barriers
for SBA service provision. The emerging themes were 1. SBA skill
enhancement, 2. application of SBA skills, 3. acceptance by the
community, 4. work environment and 5. legal/regulatory sanc-
tion. The challenges for effective task shifting of SBA services to
APs also emerged from the data. In addition, through analysis
of views and perspectives of health programme managers, we
assessed whether inclusion of APs would, on the whole, help

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community health centres (CHC) and primary health centres the system to improve SBA service provision.
(PHC) in Rajasthan and Odisha, but only at PHCs in Maharashtra.
While in Maharashtra only Ayurvedics are posted, in the other
states Homeopathic doctors are also posted. Under the NRHM, Skilled birth attendant skill enhancement
APs in Rajasthan and Odisha are given 21 days of SBA training, Skilled birth attendant training. Table 2 delineates the experi-
whereas in Maharashtra APs receive 14 days training in BEmOC. ences of APs pertaining to SBA training. The training provided
them an opportunity to independently conduct deliveries, which
enhanced their confidence. One-quarter (9/36) of the APs
Description of respondents reported that they gained knowledge about the latest SBA guide-
Table 1 describes the respondents designation and their state- lines on appropriate practices that they were unaware of prior to
wise distribution. the training. These included administration of allopathic drugs
for management of labour, newborn care practices and use of
various equipment. They also reported acquiring an important
skill of decision-making for timely referral of cases, which can
Table 1. State-wise distribution of respondents have a positive impact on preventing maternal and neonatal
mortality.
Category Rajasthan Maharashtra Odisha
All programme managers in a supervisory role (Reproductive
and Child Health [RCH] Officer, Block Medical Officers, Chief
Programme mangers (n36) 17 13 6 District Medical Officer, SBA trainers, Medical Officer In-charge of
State-level programme 1 4 0 health facility) opined that APs were more competent than
managers other nursing and paramedical staff such as Auxiliary Nurse Mid-
District-level AYUSH 3 0 0 wives (ANM). Some concerns expressed were limitations regarding
directors/officers theoretical knowledge and management of complications. A
RCH Officer/District Health 1 4 0 block-level supervisor from Rajasthan said, (R/SE/DIST2/2)_ they
Officer are competent. They can conduct normal deliveries independently
SBA Master trainers 2 2 2 but for complicated deliveries, they need assistance. They have
Chief Medical Officer/Block 5 3 4 good knowledge after the SBA training. The SBA trainers in Maha-
Medical Officer rashtra were of the view that the competency of APs was compar-
Medical Officer-In-Charge 4 0 0 able with that of medical doctors. In Odisha, the master trainer
of PHC/CHC expressed that the training of APs was a good attempt to fill the
Not available 1 0 0
existing gap in manpower for SBAs in their state.
AYUSH practitioners (n37) 15 12 10
Ayurvedic 10 12 2 Training gaps and needs. Almost one-half of the APs (15/36)
Homeopathic 5 0 8 reported dissatisfaction with the training, mainly because of
Mean age of AYUSH 33.4 45.7 32.3 unavailability of a dedicated trainer, lack of sufficient cases for
practitioners (years) honing their skills, and inadequate training material. Table 3
Mean experience in 1.5 15 3 includes views expressed by APs on training needs and gaps. An
SBA-related services (years) AP appreciated the inadequacy of training after starting SBA
service provision. He said, (O/AP/ DIST1/4) when we took the train-
AYUSH: Ayurveda, Yoga, Unani, Siddha and Homoeopathy; CHC: ing, we didnt know much. After the training when we start prac-
community health centre; PHC: primary health centre; RCH: ticing, we realized that the training was not enough. We need
Reproductive and Child Health; SBA: skilled birth attendant. more intense training. The lack of adequate hands-on practice
in conducting deliveries, especially handling complications, was

3 of 9
N. Chandhiok et al.

Table 2. Views of AYUSH practitioners (AP) on skilled birth attendant (SBA) services-related skill building and barriers to attain the skills

Conducting deliveries independently
Latest guidelines for maternity care
Drug administration
Use of equipment
Decision-making for referral to the
O/AP/DIST1/1: In SBA training, I got opportunity to perform delivery independently and the training was
much more helpful than academic training exposure
R/AP/DIST1/1: I learnt many new things such as administration of magnesium sulphate because Ive not
seen it before the training, management of PPH, uterine massage and all this, I have never done
before. It was a new thing for us. And kangaroo mother care was very new thing for us. Another thing
is proper extraction of breast milk, EBM how to give EBM if baby is in nursery
M/AP/DIST1/1: New things learnt in training were administration of Misoprostol, Prostodin, Pitocin, IUD
management, what to do for APH, we did cases at District Hospital (DH). Additional knowledge we
saw number of cases at DH, assisted, performed Breech deliveries we were not conducting, now we
can
M/AP/DIST1/6: Before the training, we were not using Ambu bags, if babies did not cry after birth. How
to use an Ambu bag was taught during BEmOC training and again in newborn care training
M/AP/ DIST1/2: Yes, we had never seen a partograph before. That time we filled 10 partographs during

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higher centre practical training. We come to know whether this mother can deliver with us or not, when do we need
to refer her, after how many hours we need to refer her, we started getting idea about referral care

APH: antepartum haemorrhage; BEmOC: basic emergency obstetric care; EBM: expressed breast milk; IUD: intrauterine device;
PPH: postpartum haemorrhage.

Table 3. Views of AYUSH practitioners (AP) on training gaps and needs

Lack of dedicated trainer
Inadequate materials (supplies and
cases for hands-on practice)
Deficient skill building on managing
complications
Need for refresher training
R/AP/DIST1/7: Yes, the training was adequate and classes were taken well by the trainer of the centre
but the gynecologist did not take classes properly. He used to come and talk to us for a few minutes
and leave
O/AP/DIST1/4: Our training on partograph could have been better. Moreover, there were not many
gloves available for the trainees to practice with their own hands
O/AP/DIST1/3: Our training is not full-fledged; we think adequate knowledge is not gained during
training. We do not get much case to practice and thus we lack confidence
M/AP/DIST1/2: Why critical case is critical, how to manage her, this should be covered. Even though we
are not expected to treat these cases, we should know the critical timeline for referral and also what
we can do at our level. Normal is focused more during the training, critical should be focused more
O/AP/DIST1/5: In my opinion, we should be provided refresher training for managing complications for
both mothers and newborn
M/AP/DIST1/3: Refresher training after 2 years for 8 days should be there, at civil hospital. It should be
practical oriented, we should see maximum deliveries, and we should see complicated deliveries

reported by one-third of the APs as a major gap in the training.
They felt that this should have been an essential component, as
APs need to take decisions on referral of cases. An AP from
Odisha articulated that the training period was inadequate to
learn all of the skills. They also felt that their training curriculum
could be more intense than other SBAs, as illustrated by an AP
from Rajasthan, (R/AP/DIST2/6) we are also doctors so the compo-
nents of the training should be modified according to our level of
understanding. The SBA training is meant for ANMs and Lady
Health Visitors (LHVs) also. As APs, we need up-gradation training.
I conducted only 20 deliveries during training. We should conduct
100 deliveries out of which at least 50 percent deliveries must
be conducted independently. The other important areas men-
tioned that need to be strengthened during training include man-
agement of complications and obstetric emergencies, newborn
care practices, episiotomy suturing, drug doses and handling equip-
ment such as radiant warmers. All APs unanimously reported the
need for refresher training for a duration of 710 days. Most of
the APs desired this to be held at yearly intervals. An AP suggested
that refresher training should be orientated to hands-on practice
and arranged at facilities where there is more patient load.
On-site skill building by a supervisor, advanced training, and
need for supportive supervision were also mentioned by the
programme managers. A SBA trainer said, (R/SE/ DIST2/ 1) there
should be supportive supervision by the Block Chief Medical
Officer or district AYUSH coordinator. There should be provision of
review of how the APs are performing and what difficulties they
are facing. We should identify if there are any barriers so that we
can remove them and ultimately include them in the mainstream
RCH.

4 of 9
International Health
Application of the skills
APs demonstrated their empowerment through implementation
of appropriate SBA skills. One AP from Maharashtra reported
discontinuing incorrect practices after receiving the SBA training,
and following the recommended protocol for prevention of post-
partum haemorrhage. He said, (M/AP/ DIST1/6) once the babys
head is out we give Oxytocin, 10 units IM, soon after delivery.
This we started after training, before training we were giving
Methergine. Before the training, we used to start Oxytocin drip
for every patient, now we have stopped this. Subsequent to the
SBA training, the knowledge enhancement led to the initiation
of other useful intrapartum and newborn care practices. An AP
from Maharashtra said, (M/AP/ DIST1/1) partograph? We were
not filling it before, now we know how to fill. We give Oxytocin
soon after birth; we were not giving this before. We look for retained
placenta. An AP reported, (R/AP/ DIST1/8) we dont use cord
clamp. I learnt in SBA training that chances of umbilical hernia
are high from using cord clamp. We use sterilized thread instead.
We clean the baby lightly and wrap it in clean clothes.
Acceptance by the community
Almost all APs reported that they were widely accepted by the
community as health providers. Furthermore, the community
did not differentiate between an Allopath and an AP. Being
included as a SBA enhanced their respect in society and also
gave them the professional satisfaction of being able to save
lives. An AP from Maharashtra said, (M/AP/ DIST1/1) being BAMS
[graduate in Ayurveda] is not creating any problem for me. The
patients come with trust. For patients we are here for 24 hours.
Patients also respect us for giving care, saving life. Society also
respects. We get encouragement; we are patted for good work.
They say, doctor has done a lot of things for us, saved life etc. We
get satisfaction because we can do something for society, by
saving lives. Conducting a delivery was perceived as a pride and
also as a contribution to the national programme aimed at redu-
cing maternal and infant mortality. However, in Odisha, three of
the ten APs interviewed reported that community acceptance
came after initial reservation and increased over time. An
AP said, (O/AP/ DIST1/4) initially people used to say, You are a
Homeopathic doctor. So you cant treat. We shall wait till sir or
madam comes. But now, even if madam is not there, people
say, Its alright even if you give medicines. Round-the-clock
availability of APs was again stated as a facilitating factor for
this acceptance. An AP from Odisha commented about accept-
ability by the community as, (O/AP/ DIST1/2) in outdoor service,
all patients come to me for check up and do not go to allopathic
doctors, this is because I stay there 24hrs, so more patients
come to me.
Work environment
An enabling work environment is an important factor effecting the
efficiency and productivity of an individual. It comes by virtue
of the perception of belongingness an individual has for the
system in which he/she is working. This perception was demon-
strated by all APs in Maharashtra, moderately in Rajasthan and
was found to be rare amongst the APs in Odisha. We analysed
the possible factors affecting this, such as non-acceptance by
colleagues, differential salary structure and type of employment,
lack of clarity on role definition and conditional opportunity to
provide SBA services.
Workplace support and acceptability. In Maharashtra, APs have
been providing SBA services in public health facilities in rural areas
for many years. They are well entrenched in the system, accepted
and respected by their colleagues. However, the situation is differ-
ent in Rajasthan and Odisha. Few APs from these states expressed
that colleagues and other subordinate staff at the health facility
did not completely accept them as a SBA. The reported reasons
for this could be perceived interference/intrusion in their area of
work. Their presence may have also affected the hierarchical rela-
tionship between the different categories of health providers.
However, the good work performance of the APs, in some cases,
led to a change in acceptability over time (Box 1).
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Differences in hierarchical relationships at the work place also
contributed to the dissatisfaction. (O/AP/DIST1/1) the 4th class
employees such as attendant, sweeper and other staff do not
respond and follow the order of AYUSH doctors. The AYUSH
doctors are treated inferior as compared to the allopathic
doctors. For example if Dr X or the in-charge says anything they
immediately do it but if I say anything they dont respond as
such. But the fact is that I do more work than anybody.
Conditional engagement and lack of role definition. Many APs
reported that they were only called upon to provide SBA services
in situations where they were the only providers available. There
was either no medical doctor posted at the health facility or the
medical doctor was on leave and the responsibility for providing
SBA services thus fell on them. One AP who had just 2 years of
Box 1. Views of AYUSH practitioners (AP) elaborating workplace
support and acceptability
R/AP/DIST 1/7: yes, community accepts me. Allopathic doctors,
ANMs, LHVs, and staff nurse sometimes make me feel that I am
interfering in their work and practice. There is one lady doctor
[female doctor] who does not like the fact that I am conducting
deliveries
R/AP/ DIST 1/1: we are always treated as second grade citizen.
They accept us to a very less degree. If I do any good, they will say
a practitioner from our department has done a good job. And if
anything bad happens, they used to blame it all on us saying oh
because of AP, because he is an AP, all the mistakes have
occurred
R/AP/DIST2/3: initially, I felt little difficult to adjust. It is like
foreign body to a facility. But when foreign body works well
people understands the utility. Sometimes, I feel that ANMs, LHVs
are not ready to accept us from their attitude and behavior. They
try to keep us away from delivery. Just day before when I was
going to attend a delivery, but ANM said that it will take time. But
patient delivered soon. Such thing brings down our esteem in front
of attendants
ANM: Auxiliary nurse midwives; LHV: Lady health visitor.
5 of 9
N. Chandhiok et al.
experience in maternity care reported managing the CHC single-
handedly, said, (O/CHC/DIST2/1) I am an AYUSH medical officer
in this hospital. I manage the entire hospital alone. This is an
upgraded CHC. I stay here 24 hours. There is no other full-time
doctor in this hospital. Only a visiting doctor [MBBS] comes to this
hospital and provides his services just 8 hours per day. Dr Y is
the in-charge of this hospital and he is a MBBS. He stays 15 km
far away from this hospital at Z. I have conducted near about
360 deliveries in this hospital.
One AP from Rajasthan also reported conducting a delivery as
the female doctor was not available: (R/AP/DIST2/7) lady doctor
was on leave so I was given ANC (antenatal care), deliveries and
PNC (postnatal care) duties. I conducted 121 deliveries in those
6 months. In the last one year I have conducted 194 deliveries.
Every time, the lady doctor is not available in the hospital, I take
care of ANC, delivery and PNC.
A significant number of APs interviewed reported not shoulder-
ing the independent responsibility of conducting deliveries. This
could either be due to lack of confidence to conduct deliveries
or lack of opportunity as an established provider was already
present, who is also well-known in the community. One AP said,
(O/ANA/CHC/1) I do not conduct deliveries if I do not get any assist-
ance or if I am alone. Patients refuse the services if Dr X is not
available on duty. Similar practice was reported by an AP from Ra-
jasthan, (R/AP/DIST2/1) yes, I conduct deliveries. I have done 11
deliveries in the last months. One was independently conducted
by me. The remaining 10 was assisted by me while the in-charge
carried out the procedure. In-charge is local person and most
patients come in his name only.
Differential salary structure. The salary that APs are getting is
less than their counterparts from the allopathy stream. Unlike
the other health providers who are permanent employees, the
appointment of APs is contractual for a fixed tenure. This discrim-
ination also contributed towards workplace tensions. An AP
lamented, (O/AP/DIST1/5) our salary is 10 500, the salary of a
new comer [allopath] is around 25 00030 000, and that is why
they have ego, why this difference is there? You can see by yourself
that AYUSH doctors are also doing treatment whereas allopathic
doctors do not remain there, for example at headquarter, he is
not there, they come at 9:00 or 9:30 am and go by afternoon
12:00 pm because of work pressure. He has ego. Because I am
in-charge, he does not talk to me. An AP from Rajasthan
pointed out that APs are discriminated in the case of salaries as
well as promotions and hence the allopath providers consider
them inferior: (R/AP/DIST2/6) the doctors still consider that we
are subordinates and a lot of competition also exists. They also
get more salary than us as they are permanent employees. Even
if a junior MBBS joins our facility, he will be considered for the
post of officer-in-charge and not me.
Lack of legal/regulatory sanction
Lack of clarity around job descriptions, policy, and legal contexts
and implications hindered APs in providing SBA services. An AP
said, (O/AP/DIST1/5) an authorization letter from Chief District
Medical Officer should be sent to the local health centre authorities
to allow the APs to conduct deliveries after they are trained in SBA,
because the Medical Officer-in charge would say, you are sent for
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training, thats fine. But there is no order to allow you to conduct
deliveries. These factors affected the confidence of APs to
provide SBA services. An AP from Rajasthan said, (R/AP/DIST1/5)
I can follow the guidelines but initially I feel less confident to
carry it out when other staffs question me about legal implications.
I am comfortable but sometimes others question me if I am
authorized to use the medicines and whether I know how to
handle complications caused by the medicines. It irritates me.
Views of programme managers on engagement of
AYUSH practitioners in skilled birth attendance services
It was evident that programme managers were in favour of
engaging APs in the provision of SBA services. The APs were per-
ceived as hard working with a will to work in rural areas where
there is a shortage of providers, as exemplified by this quote,
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(M/State/3) they willingly work in rural areas, continue to serve
for many years, and are willing to work even in adverse conditions.
Generally they are hardworking, and sincere. Most come from rural
areas and want to go to rural areas for practice. Hence they willingly
work in rural areas.
The programme managers reported the integration to be com-
plementary to the system because it provided additional skilled
and trained manpower. A programme manager supported his
argument by giving an example of successful task shifting of the
immunisation programme to APs. He reported, (M/state/2) there
are advantages as we get trained man power. It helps in filling
the gap of trained care providers. They manage immunization pro-
gram quite well. Programme managers suggested that based on
their competency, experience and performance, APs should be
rewarded by providing them some appreciation/incentive. This
would encourage them and promote effective integration. A dis-
trict supervisor said, (O/SE/ DIST2/3) because these people [APs]
have been given some skills, for performing APs, some sort of
push must be given. After a lot of persuasion, they have been
given this charge [they have been allowed to conduct deliveries].
Suppose, after SBA training, somebody has conducted 500 deliver-
ies then the AP can be sent for EmOC (emergency obstetric care) or
BEmOC training.
Programme managers shared divergent views on support and
acceptability of APs by other providers in the existing health
system. Concern was also expressed about unclear policy/legal
environment about their role as a SBA. A programme manager
said, (R/SE/DIST1/1) they should be reviewed monthly. Full
support from the system is needed. I have heard complaints that
at some PHCs, the medical doctors are not allowing them to
enter the labour room. Also, one in-charge was not cooperating
with an AP to buy supplies. There may be some legal complications
for using the allopathic medicine as the APs are not registered
midwives. Lack of both peer-support and recognition of their
hard work was expressed as a concern by programme managers.
(O/SE/DIST2/1) he may be delivering about 40 women per month.
But what do they get? No recognition, no inspiration, no encourage-
ment. Nowadays, you know you are engaging ASHA [community
link worker]; you are giving them award. But these people are
being treated as underdogs [inferior] by our allopathic medical offi-
cers. The place where this fellow is staying [pointing at an AP],
another allopathic doctor is posted. He [the allopathic doctor] is
creating hurdle for him [the AP] to conduct deliveries.
International Health
However, a programme manager from the same state
deferred with the above opinion. He said, (O/SE/DIST1/2) I dont
go to supervise at their worksite. But I hear that most of them
are doing well. APs need to get recognition in their workplaces.
Not all of them are pro-active. Those who are eager to learn get
support from the staff and also patients come to them.
Discussion
To address the prevalent shortage and maldistribution of specia-
lised health professionals to deliver SBA services in India, a strat-
egy of task shifting, by optimising providers of the traditional
Indian systems of medicine (APs) to deliver these services,
has been initiated at public health facilities in rural areas of the
country. Task shifting is being implemented as a pragmatic
response to health workforce shortages to various degrees in a
number of countries, and there is extensive evidence in the litera-
ture that some forms of task shifting have been adopted informally
in response to human resource needs throughout history.10 Besides
midwifery, there is also evidence of successful task-shifting models
for other conditions affecting resource-constrained settings.17 But
for any new approach to be successful, it requires a clear-cut imple-
mentation strategy so that it is safe, efficient, effective, equitable
and sustainable.
We conducted a multisite qualitative study among key pro-
gramme stakeholders such as APs and different categories of pro-
gramme managers to analyse the possible factors that could be
barriers/challenges for successful integration of APs as SBA provi-
ders. We also tried to identify their training needs. The study find-
ings would help in effective country-wide scale-up of this
Figure 1. Factors affecting integration of AYUSH (Ayurveda, Yoga, Unani, Siddha and Homoeopathy) practitioners in skilled birth attendant (SBA) services.
intervention and promote mainstreaming of APs into the existing
healthcare delivery system. On analysis of the interviews, the two
key elements identified as crucial to successful task shifting were
skill enhancement and an enabling work environment. We
propose a framework of factors affecting effective task shifting
and subsequent successful integration of AYUSH provider for
SBA service provision. (Figure 1).
The SBA training received by APs, using a competency-based
standardised curriculum and designed to meet the roles, compe-
tency levels and standards for performance as a SBA, enhanced
their knowledge and competency levels. Although APs are sup-
posed to conduct normal deliveries only, the results indicate
their zeal in learning specialised practices such as management
of complications during childbirth. The programme managers
found the APs to be enthusiastic, hardworking and competent,
with good acceptability in rural areas. They further felt that
depending on their performance as SBA providers, their skills
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could be upgraded through provision of BEmOC training.
However, this may warrant further research as a study carried
out in India indicated that SBA-trained APs and nurses were
unable to identify unusual presentations, while EmOC-trained
medical doctors performed better on this aspect.18 Importantly,
inadequacies in the training programme reported by a large pro-
portion of APs need to be considered. The lack of sufficient train-
ing material and cases for hands-on practice, a need for
dedicated trainers, and increased focus on areas that need
strengthening such as newborn care practices and management
of complications needs urgent redressal. There was also a strong
desire for periodic refresher training. This would allow for
improvement of the skills necessary for APs to perform their
7 of 9
N. Chandhiok et al.
assigned tasks and facilitate continuous improvement in the
quality of services they deliver.
The success and effects of task shifting are dependent on
varying local health contexts and are shaped by a range of
often very different social, political and cultural systems.19 We
also found varying levels of acceptability and integration among
the three states, with Maharashtra demonstrating the best and
Odisha the least. This could be attributed to the fact that APs
have been employed at peripheral health centres in Maharashtra
for more than a decade and are well entrenched in the health
system, whereas in the other two states appointment of APs is
a recent intervention under the NRHM and would take time to
become accepted. Public health strategies are governed by state
administration in India and this could have led to the variation
between states in implementation of the programme.20
The success of integrating APs to provide SBA services would be
dependent on the ability to create an enabling environment. We
analysed the factors that posed as barriers for this and cate-
gorised them under: workplace support and acceptability; condi-
tional engagement and lack of role definition; differential
remuneration; and lack of legal/regulatory sanction.
Lack of workplace support and acceptability can restrict APs
from providing SBA services, prescribing medicines or by giving
them a secondary role. This study indicated that there was reluc-
tance in acceptance of APs by other health providers, more in the
nature of protection of professional turf. Similar sentiments
have been echoed in other studies.21,22 A complex relationship
and professional hierarchies exist between providers, and while
redesigning roles and responsibilities, ways of managing these
interprofessional dynamics need to be explored. To increase the
acceptance of APs as SBAs, sensitisation of primary healthcare
providers about new task-shifting strategies and its importance
should be an integral part of planning and roll-out.
A clear definition of roles is the basis for organising the redistri-
bution of tasks and is essential if services are to function in a
coherent and effective way. This study indicated that there was
ambiguity in role definition of APs. Rather than providing SBA ser-
vices on a regular basis, in some situations this led them to only
provide SBA services when there was no other provider available.
In Maharashtra, the role definition was clearer and APs were at par
with their counterpart medical officers with respect to their
responsibilities and position in the health system. However, this
was not seen in Odisha where not only was there less clarity on
the role of APs but the differentials in salary structure and the con-
tractual nature of appointment under the NRHM demotivated
them and made them feel slighted from other providers. Role
definition provides shared understanding of tasks and responsibil-
ities, levels of authority to make decisions within the health team
(including when to refer patients to a more appropriate cadre) and
what skills and qualifications are necessary to carry out the
responsibilities that are assigned.23 A systematic review of evi-
dence on integration of traditional birth attendants in formal
health system to increase skilled birth attendance in Malaysia
identified role definition as a singular intervention that increased
SBAs at home births from 35 to 63%.24 As per WHO guidance,
task shifting might affect interprofessional relationships because
of concerns of higher cadres regarding accountability, medical li-
ability, and ability of lower cadres to handle complex situations.19
Need for supportive supervision and performance review of
APs was identified by a SBA trainer as a strategy for effective
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mainstreaming in the programme. It would also identify barriers
that prevent them from conducting deliveries independently.
Various studies suggest that supportive supervision is conducive
to improvements in health worker performance and to a more
general strengthening of health systems.25,26 In particular, research
has found that the integration of supportive supervision into
primary healthcare models in developing countries can lead to
improvements in the delivery of health care by most levels of
healthcare worker.27 Whatever the initial education, experience
or training, most of the studies addressing training argue that
ongoing support and clinical supervision are critical.28
Vague legal and regulatory sanction was identified as an
important barrier both by APs and programme managers. A for-
mal authorisation to provide SBA services was lacking and there
was no recognition of the work done. Moreover, APs prescribing
modern medicines may be in conflict with current health profes-
sional regulations, and APs felt that they do not have any legal
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protection for the additional tasks. The legal protections and liabil-
ities and regulatory framework that may require policy, strategy
and legislation changes must be done for their inclusion as SBAs.
Credentialing of APs as SBA providers could give them formal recog-
nition and benefit them as well as the service users, increase
their acceptance both in the community and with other health pro-
viders, and could include a range of quality assurance mechanisms
such as licensure, registration, certification or accreditation. Greater
confidence, increased job satisfaction and more rapid career pro-
gression can result from credentialing.29
To the best of our knowledge, this is the first study that has
explored the barriers/challenges to integration of APs for provision
of SBA services from three states in India. The primary purpose of
the study was to identify the felt gaps in their environment that
prevented them from performing as SBA providers, amidst a
serious shortage of manpower in the health system. Major limita-
tions of this initial investigation include the purposive nature of
sampling and the small sample size, limiting generalisability.
However, the study provides important clues of the challenges
in mainstreaming the large number of professionally trained prac-
titioners of alternative systems of medicine in India for effective
primary care delivery particularly in the areas of maternal and
newborn health.
Conclusion
Integration of APs to provide SBA services could prove to be an
effective step in combating human resource shortage in rural
India. Inadequate training, poor clinical support and supervision,
and haphazard implementation could undermine the confidence
of APs in using their new skills. Making systematic efforts to
provide an enabling environment including credentialing APs,
and quality skill enhancement measures followed by supportive
supervision could be the key determinants of their acceptance
in the health system.
Authors contributions: NChan conceived the study and participated in its
design and co-ordination; AS, PC and NChau collected the data; NJ, AS, PC,
NChau and SS interpreted the data; NJ performed the qualitative data
analysis; NChan and NJ drafted the manuscript; AS, PC, NChau and SS
International Health
contributed to drafting of the manuscript. All authors have read and
approved the final manuscript. NChan and NJ are guarantors of the paper.
Acknowledgements: The Indian Council of Medical Research extends
its gratitude to the Ministry of Health & Family Welfare (Government of
India) and WHO for providing technical inputs and financial support for
this study. The authors thank the National Rural Health Mission, the State
Directorate of Health Services and the Chief District Medical Officers of
the six selected districts for all their support throughout the study.
Finally, all of the AYUSH doctors, staff at the health facilities visited and
members of the research team deserve sincere acknowledgment for the
unparalleled assistance rendered by all in completing this study.
Funding: Funding support for this study was provided by WHO, WR India
country office [APW Regn. No 2010/1118010].
Competing interests: None declared.
Ethical approval: The National Ethical Committee of the Indian Council of
Medical Research reviewed and approved the study [letter no. 47/7/
2011-BMS/IEC dated 4 February 2011].
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