Meeting the Primary Health Care Needs of Rural Assam through introduction of a mid?level health worker: Lessons from India’s experience with Rural Health Practitioners

Background: The introduction of a three years Diploma in Medicine and Rural Health Care (DMRHC) course in 2005 under the purview of Assam Public Health Act has lead to augmentation of human resources through deployment of Rural Health Practitioners (RHPs) in Assam, India. Objectives: The study aimed to understand the performance of Sub-Centers (SCs) in terms of ranges, uptake and quality of primary health care services in SCs with and without RHPs over consecutive three years since deployment of RHPs at Health Sub-Centers (HSCs) in April, 2008. Methods: We used mixed research method i.e. qualitative technique complemented by quantitative analysis of data. Purposive sampling method was adopted for selection of HSCs in High Focus Districts (HFDs) where RHPs were deployed. Key Informant (KI) interviews were conducted comprising of RHPs, Auxiliary Nurse Midwives (ANMs), beneficiaries and government officials to gain perspectives about RHP model, service delivery and challenges etc. Semi structured, open-ended questionnaires were used for KI interviews and checklists for community group discussions. Results: Performance of HSCs with RHPs has improved substantially in terms of management of Out Patient Department (OPD) cases and institutional deliveries as compared to HSC without RHPs over the years from 2010-11, 2011-12 and 2012-13. RHPs cited DMRHC was apt for serving the rural population. Key challenges include lack of referral transport, housing and promotion avenues. ANMs, beneficiaries and community perceptions of RHPs are positive in terms of managing increased number and types of common ailments, drugs availability, improved care, proper referral and initiation of institutional deliveries. RHPs had gained community‘s confidence in service delivery at HSC. Conclusions: Replication of RHP model is critical for improved rural health care systems, provided supervisory and support mechanisms are streamlined. Recognition of DMRHC, upgrade to a Bachelor’s degree course and creation of regular cadre is necessary for sustainability of rural health systems.