User:Drmkraj

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Rural Medical Assistant

Rural Medical Assistant The Post RMA is Just below the Medical officer and Above the staff nurse . They Working Both Clinical and Administrative work . Clinical: In case of any medical emergency or accidents, provide first-aid, primary medical care or stabilize and then refer to higher centers.Provide curative care for common illnesses and disorders. Provide basic maternal and child health care, conduct delivery, basic management of complication so f pregnancy and childbirth. Performs impleoperative procedures–suturing and dressing of small wounds, drainage of abscess; management of burns, application so splinting case so fracture, application of tourniquet in case so bleeding etc. Administrative: In charge of PHC in the absence of MBBS doctor and implemental national and State level health programs Authorized to operate bank accounts. Provides Supervisory support to peripheral health staff and conducts Saturday Sector meeting. Leads preventive health education and community mobilization.

Content

  • • Problem Scenario
  • • The Philosophy
  • • 3 ½ Years Medical Course [P.M.H.M.]
  • • Detail Of Course
  • • PMHM Syllabus
  • • Outcome of Course.
  • • Result
  • • New Possibility
  • • External Links

Problem Scenario - The state of Chhattisgarh was carved out of south-eastern Madhya Pradesh (M.P.) in late November) 2000. With regard to key socio-economic and health indicators (including IMR and MMR), this state lags behind the rest of the country. Although geographically the ninth largest state, covering 135,194 sq.km, its rank by population size would be much lower as its population of 20.83 million (2001 Census) is dispersed with a population density which is half that of the national average (154 for the state as against 312 per sq.km for the country). One thirds of its population is tribal, the highest amongst large states and 40% of the land areas is classified as forest lands, Of the 18 districts of the state, 12 are classified as remote, tribal and extremist affected areas. Providing health care is a human resource intensive activity, and in Chhattisgarh state the shortage of trained health care providers is among the most acute in the entire country. The state has 4692 sub-centers sanctioned and of these almost one-third do not have even a single ANM, though they are expected to take on two ANMs. Only 540 staff nurses are available against the 1344 required by IPHS norms for working in primary and secondary public health facilities in Chhattisgarh (National Health Systems Resource Centre (NHSRC) and Academy of Nursing Studies, 2009). The shortfall for doctors both MBBS graduates and Specialists is about 72%, with 1455 medical officers posted at PHC against the posts of 1737 and only 247 specialists available against the sanctioned 637 posts (State PIP 2009-10). The shortfall in doctors is even more severely felt as the vast majority of the inadequate numbers that do exist are located in urban or semi-urban areas, with certain large tracts of rural and tribal areas almost devoid of even a single doctor-( with MBBS qualification). At the time of its bifurcation from the state of Madhya Pradesh,, Chhattisgarh had no government nursing college and only a single private college of nursing admitting 30 students for a four year BSc Undergraduate degree course. . Four years after the creation of the state, the Government College of Nursing started functioning at the state capital, Raipur, with an annual intake of 33 students. At present there are 2 colleges that offer postgraduate programmes in nursing (M.Sc), 10 colleges that offer undergraduate degree courses in nursing and 4 that offer diplomas in nursing (GNM) all of which are in the private sector. In 2000, there was a single medical college in the entire state admitting 100 students, and even this was considered one of the least favored medical colleges by students in undivided Madhya Pradesh. This was because it was relatively poorly staffed and a limited reputation for quality and outcomes. This college had to be strengthened after the creation of the state, and a second medical college opened in August 2002, got recognition in 2006 and a third was initiated in July 2007. Two further medical colleges remain in the pipeline. Though for a state these are rapid strides forwards, it would be quite some time before this would translate into increased recruitment in public sector recruitment. The immediate impact of a new states was a stagnation or even a small drop in the 3 number of doctors in 2006 as compared to earlier (see table 1) which could be due to the fact that the rapid urban and industrial development of the state could support a larger number of doctors in private practice. In the year 2001 only 516 medical officers were available at PHC level out of total of 1455 sanctioned posts.

The Philosophy - The initial idea of a 3-year diploma course for training a health care practitioner for rural areas stemmed from the new Chief Minister’s office and was a result of his direct intervention. The initial logic was that if candidates from rural areas are brought into a 3-year diploma programme, they would be more likely to return and serve in such areas. Their opportunities for urban private sector employment would be less. Another rationale that was articulated was that a formally trained skilled provider in the underserved areas of Chhattisgarh would serve as a better than to the “jhola chaap” doctors practicing in these regions. This is a term that derisively refers to the unqualified practitioners of modern medicine that has mushroomed over the villages. Given the fact that the outcomes from new medical colleges would take over six years to be visible, a three year course would yield results within the political lifespan of the government of the time. Moreover, starting new medical colleges, conforming to guidelines of the Medical Council of India (MCI) required significant capital investment from the government and recruitment of human resources. Even if the financial resources were to be found, the human resources would be difficult, for even the existing state college in the state capital was facing shortages of key faculty members.

3 ½ Years Medical Course [P.M.H.M.] From early 2001, when discussions to the three year course began, opposition from the Medical Council of India, the professional council regulating medical education, was anticipated. In discussions shared among the Health, Law and General Administration Departments, it was agreed that the powers of recognizing the council which would approve the three year course should be given to a body created for the purpose through an Act passed in the Chhattisgarh state legislative assembly. The MCI would thus not have to approve the course. Such a State Act could be passed by the state without requiring the approval of the central/federal government or the president. MCI was however contacted and they formally rejected this course, even without going into any discussion of objectives or course content. The Chhattisgarh government however proceeded, using existing precedence of West Bengal having briefly implemented such a course and with the knowledge that in Maharashtra and Karnataka, where similar courses had been implemented. The operationalization of the plan was given great urgency by the political leadership. Within days of the decision, a committee was formed in the Health Department. Within the month, a committee of senior secretaries presided by the Chief Secretary forwarded a letter of approval to the Chief Minister (CM). Still within the same month, the CM signed for the legislative assembly to meet to consider a proposed bill. The very next month the assembly met and passed the act. The notification rules were drawn out and printed as an extraordinary Gazette on 18 May. The state assembly accepted these rules four days later and the e Chhattisgarh Chikitsa Mandal (CCM) came into existence. One important reason for such a quick process was the clearance or no objection from the Finance Department. The principal reason for quick clearance by the Finance Department was the explicit understanding that the CCM would be an autonomous body with no financial burden to the state government. The CCM was expected to raise its own finances through fees charged from private agencies in return for being given permission for starting institutes which would run these 3-year courses and later to be supplemented by through registration fees charged to graduating three year doctors. Private managements of these institutions were expected to recoup these losses and make a profit through tuition fees. The costs to the government of running the 5 CCM were expected to be minimal with a total of only three officials linked to the new registration body; all of whom were already on government payrolls and were being seconded for the task. The CCM comprised the Director of Health Services as President, the Dean of the Medical College in the state capital as Vice-President and a district chief medical officer to be seconded in as Registrar. With such limited initial capital and human resources in CCM, the new registration body was a limited institution. The powers that the CCM was authorized with, however, were not so limited. It was initially given several responsibilities: (i) to inspect private bids made for starting the new institutes for the 3-year courses, (ii) to be the nodal authority in-charge of the admissions process of the students to these institutes, (iii) to have power to change the syllabus of the course, (iv) to fix norms and guidelines for charging tuition fees for the 3-year course, (v) to be the authority charged with undertaking the examinations process as well for this course; and (vi) to be the registration body for graduates from the 3-year course. These were far more powers than the state medical council had and even more than the Indian medical council had for its regulation of medical courses.

Detail Of Course - Since the 3-year course was not going to be public funded, the institutes for imparting this education were all planned to be private. The locations proposed were in rural/tribal districts, but with access to a large government hospital usually the district hospital to make it possible for clinical teaching and internship. Fifteen applicants responded to an expression of interest advertisement by the government. It is notable that although the CCM was charged with the responsibility of initially inspecting the infrastructure and facilities available for the first year of non-clinical teaching alone, the final selection of the initial three institute locations was solely with the state government. First three colleges were inaugurated in October, 2001 at Ambikapur, Jagdalpur and Pendararoad. At this stage, the syllabus for the remaining two years was still not prepared. Three further institutes at Kwardha, Katghora and Kanker opened a year later in end 2002, with two of these going to two owners of the first batch of institutes opened. Although initially it was decided that each institutes would have maximum of 100 students, all the six institutes were allowed to admit 150 students per year. The student admission was in three categories: 1. 50 % free merit seats – 75 seats, 2. 35% payment merit seats – 53 seats 3. 15% NRI seats – 22 seats. There was only a 20-day period for applications to the first three institutes, but even in this short time there were approximately over 9,000 applicants who applied for admission to these three institutes in the first year. Admissions happened for three years before the course was stopped. For the first year, CCM conducted the admissions as per the provisions of the Act. In the subsequent years when the institutes took the lead through an association they formed called the “Three Year Medical Institute Association of Chhattisgarh” (TYMIAC). The cut off for the 6 admissions of the first batch was 75% in the required the school-leaving examination, with inclusion of Biology being compulsory. In the first two years, eligible candidates were called for interview in the order of their scores in the school leaving examination, and given the seats in the institutes of their choice, against vacancies that existed at the time of their appearance- a process that has of late being called counseling – though in fact no counseling occurs. This counseling was centralized and held at Raipur. In the third year of admissions, even this centralized counseling was given up and admissions were directly done at each institute. For entry to the third batch, there was a significant fall in the number of interested applicants as compared to the first batch.

  • • Year2001-Discuss on started with in government for three year Medical course. By Former Chiff Minister Mr. Ajit Jogi.
  • • March2001-Medical Council of India refuses the proposal. Fortunately “health” is a state subject.
  • • 18th May 2001-Chhattisgarh Medical Board was established. Decision take into start “Diploma in Modern Medicine & Surgery”.
  • • October 2001- Three institutions–all in private sector and located in remote rural areas-were affiliated to existing universities for higher education, finally started the course.
  • • Anusha Memorial Medical institute Pendra Road Bilaspur
  • • Maharshi Anstang Medical Institute Ambikapur
  • • Bal Gangadher Tilak medical institute Jagadalpur
  • • 3 new Medical Institute Started in 2003
  • • Kedarnath institute of medical science katghora
  • • July 2004 –name of the course changed to “Practitioner in Modern and Holistic medicine”.
  • • 2004 –the course is challenged by the Indian Medical Association in the High Court. Admissions stopped
  • • Course curriculum revised –to include orientation to prevailing diseases such as Malaria, diaherrea, TB.
  • • May 2006 –First batch passed out.
  • • Feb 2007 –The period of compulsory internship changed from 6 months to 1 year.
    PMHM Syllabus - General Anatomy

• Introduction to anatomy • Classification of joint and Bones • Introduction nervous System Cardiovascular System • Lymphatic System Upper Limb -: • Muscles of Pectoral Region, Back, arm, fore arm, and Hand. • Lymphatic Drainage of Mammary Gland along with Axially Lymph nodes • Brachial Plexus and major Nerves upper limb along with effects of nerves injuries • Blood Vessels of upper limb. • Palmer Spaces. Lower Limb -: • Front of thigh, with femoral triangle, femoral sheath, sub sartorial canal. • Muscles of different combatant of thigh. • Gluteal Regian. • Different compartments of Leg. • Foot (Different Muscles, nerve, vessels) with mode of inversion and Arches of Foot. • Venous drainages & Lymphatic drainage of lower limb. Thorax -: • Boundaries of inlet, Outlet, description of contents of intercostals space mediastinum. • Pleura. • Lungs and Broncho Pulmonary Segments. • Pericardium and Heart. • Oesophagus Thoracic duct. Abdomen -: • Anterior abdominal wall inguinal canal and rectus sheath. • Scrotum and testis. • Peritoneum with different pouches, spaces and Ligament. • Different viscera of abdomen. • Abdominal aorta and its branches. • Perineum. Head and neck -: • Scalp, Face. • Deep fascia of the neck. • Triangles of the neck. • Thyroid gland. • Carotid sheath and Branches of External carotid artery. • Parotid Gland, submandibular gland. • Infra temporal fossa, with mandibuler Nerve. • Pharynx. • Larynx. • Nose, Tongue, Middle ear. Brain -: • Meninges and cerebrospinal fluid. • Blood vessels of Brain. • Spinal Cord. • Medulla Oblongata. • Fons. • Mid Brain. • Cerebral Hemisphere with sulci, Gyri, and functional areas. • Internal Capsule. • Brief ideas about Basal Ganglia & Thalamus Hypothalamus. • Motor and sensory pathways. Embryology -: General -: • Spermatogenesis, Oogenesis & Fertilization. • Formation of embryonic disc and differentiation of three gel, Layers & Finding. • Formation and function of placenta. Placenta barrier. Systemic Embryology -: • Cardio Vascular System, Heart Tube & its dilatations., Formation of different chamber of heart, Developmental anomalies Brachial arch arteries and formation of Major arteries and its Anomalies. • Urogenital System formation of kidney, Ureter, Urinary Bladder and associated anomalies. Formation of Testis and Ovaries. Formation of Uretus, Fallopian tubes, vagina and associated Anomalies. • Development of Respiratory system. • Development of gastrointestinal system. • Development of face, Palate. • Development of Development of Brachial arches and Pouches. • Formation of Neural Tube and Brain Vesicles. Practical -: • Demonstration of dissected part of the body and wet specimens. • Demonstration of bones and models. • Demonstration of skiagram. • Demonstration of surface anatomy on living body PHYSIOLOGY

THEORY Blood _-: Composition of Blood, Properties of blood , Plasma, Plasma Proteins , RBC, WBC, immunity blood group, blood transfusion, Clotting of Blood and its fate.

Cardiovascular System -: Cardiac cycles , action of Valves, Heart Sounds apex beat cardiac, coronary circulation, electrocardiogram, Pulse, Blood Pressure and its regulation. Reticulo, Endothelial system, Lymph (Introduction) Kidneys and Excretion -: Functions of different parts of nephron, function of kidneys, mechanism of formation of urine, composition of normal and abnormal urine, testes of abnormal constituents. Respiratory System-: Mechanism of respiration, respiratory centre and regulation of respiration, Lung Volumes and capacities, Oxygen and CO2 content of arterial & Venous Blood anoxia , Apnea, Cyanosis, Asphyxia, Dyspnoea, Artificial Respiration & its Technique. Digestion -: Physical Process of digestion, Functions of stomach small and large intestine, Digestive juices, Saliva , gastric Juice, Pancreatic Juice, Bile, Intestinal Juice, Liver and Their function and defecation. Introduction of Endocrine their Dysfunction, and Reproduction -: Menstrual cycle, Pregnancy, family Planning, Applied aspect of Central Nervous system, Reflexes, Voluntary Movements, Paresis, Paralysis, Speed, Speed, Speech & Voice. Special Senses-: Ear, Nose, Tongue, Anus, Skin ets. Ophthalmology Vision Physiology of Vision, Errors of Refract on Hearing. 


                                    PRACTICAL

HUMAN PHYSIOLOGY -: • Examination of redial pulse. • Examination of heart. • Recording of blood pressure. • Auscultation of Heart sound. • Co-relation ship between arterial pressure & Exercise. • Determination of Vital capacity. • E.C.G. • Artrificilal respiration. • Superficial and deep reflexes. • Pupillary reflexes. • Muscle power and co-ordination. • Acuity of Vision field of Vision. • Hematology-: RBC count, Total WBC count, DLC, ESR,MOH, MCHO, Hemoglobin Estimation, Blood Grouping, Rh Factor, Packed cell volume, Bleeding time, Clotting time. BIOCHEMISTRY

SECTION -1 CHEMISTRY OF BIOMOLECULES [A] CORBOHYDRATES:- • Classification of isomerism, epimere, mutarotation, monosaccharide important. • Properties of monosaccharide, Physiological significance of monosaccharide, biomedical importance of monosaccharide glycosides, important chemical reaction of monosaccharide • Disaccharide, Important properaty of disaccharide, biomedical important of disaccharide, • Oligosaccharide, Polysaccharides, Clinical Orientation of Carbohydrate. [B] LIPIDS -: • Definition and classification of lipids simple lipid fats, properties of fats. • Identification of oils and fats. Biological importance of simple lipids. • Compounds lipids , classification, biological function, physical and chemical Properties. • Derived lipids, Fatty acids, types of fatty acids, Properties & imporatance of derived acid, Property and function of essention fatty acids. • Cholestroll, structure, Type of Cholestroll, Properties of Cholestrol., Biomedical important of cholesterol and other steroids clinical orientation of lipid. • Prostaglandin , Defination Classification, Chemistry of Prostaglandin, Mechanism of action of Prostaglandin. Functions of Prostaglandin. Biological Importance of Prostaglandin. [C] Proteins and Amino Acids -: • Definition of Proteins, Classification of Proteins, Stuructural organization of proteins Properties of proteins, Bonds involve in Protein structure, Estimate of Proteins, Purification of proteins, Clinical Orientation of Proteins. • Amino Acids :- Structure and classification of amino acid, Properties of amino acid, Separation and identification of the amino acid Presents, Biological important of Amino acid. [D] Immunoglobulin, Nucleic acid and chromatin -: • Immunoglobulin definition, classification, Properties of immunoglobin, Hapten, Menoclonal antibody, clinical orientation, • Nucleic acid DNA, Chemistry of DNA, RNA, Chemestry of RNA, Sturcture organization of DNA, RNA. Biological importance of Nucleic acid. [E] Hemoglobin, Porphyrin and Bile Pigment -: • Hemoglobin Structure, Regulation of hemobiosythesis, Property of Hemoglobin. • Thalassemoa , Sickle cell Anemia, Porphyrines, Catabolism of Hemoglobin, Metabolism of bile Pigments, Joundice Gilbert Disease, Clinical Orientation.

SECTION -2 METABOLISM

[a] CARBOHYDRATES -: • Digestion and absorption of carbohydrate, metabolism of carbohydrate, Utilisition of Glucose, Glycogenesis. • Cyclic AMP, Cyclic GMP, Glycogenolysis, Glycolysis, Oxidation of Pyruvate to Acetyl COA. Citric acid cycle, futile cycle, gluconeogenesis, HMP Shunt, metabolis of Fructose, Meliluria, Lactosuria, Fructosuria, Pentosuria, Diabetic mellitus, Diabetic Ketoacedosis. [b] LIPIDS -: • Oxidation of triglcerol, B-oxidation of fatty acid. Biosynthesis of phospholipids. • Prostaglandin, Lipids Transport, Role of live metabolism, Cholesterol metabolism [c] PROTEINS -: • Metabolsi of Proteins, Transamination, oxidative D animation, Urea cycle, Test of urea in Urine, Metabolic disorder in urea, Glutathione, catabolism of amino acids. Creatinine and creatine, G-Protein, Protein Urea.

Practical -: • Analysis for Carbohydrate Protein, Lipid analysis. Analysis of different food constituents, • Normal Urine analysis, Estimation of blood glucose, Urea, Uric acid, Creatine, Serub Bilirubin, Cholesterol, Total Protein, Gastric Juice analysis, Vitamin –C 


           SECTION -3

CLINICAL BIOCHEMISTRY

• Enzymes and isoenzymes of clinical importance. • Vitamins and diseases related Vitamins Defiecincy. • Water and electrolytic Balance & imbalance. • Redioactivity and Redioisotops in medicine. • Osmosis and Osmotic Pressure. • PH buffers, Indicators, surface cession acidity and alkalinity, Transport through Biological cell membranes. • Metabolism of xenobiotics, Recombinant DNA Technology, Thyroid Function Test, Liver Function Test, AIDS, Gastric Function Test. 

       PREVENTIVE AND SOCIAL MEDICINE

• Concept of Health, Principal of Epidemiology and Epidemiological Method. • Analytical and Experimental Health advise to Travelers in Brief. • Screening of Diseases, Epidemiology of Communicable diseases. • Respiratory infection, small model for eradiacation of infection diseases others diseases. • Zoonosis Yellow fever. Others Arboviral diseases, KFD, &others Diseases. • Epidemiology of non communicable diseases, • Health programs in India, Including all national Program with addition of present strategies. • Monitor and Evalution indicators for each Program , Role of NGO and International Health. • Organizations of health Program, demography and family Planning, Record keeping in Family Planning, newer Techniques of contraception both temporarary and Permanent. • Preventive medicine in obstratic and Pediarics and RCH, • Nutrition and Health, Nutritional Requirements brief for carbohydrate fat and proteins. • Nutritional factor in selected diseases. Social science and medicine. • Environmetn and health, • Water hand pumps and tubewell details, water purification electrical application. • Disposal of wastes, Medical entomology with present control strategy,. • Occupational health , Mental Health Information. • Medical statistis, Health Education and Communication. • Cycles of behavioral changes, interpersonal Communication conflicts counseling. • Health Planning and Management, Planning, and Management, • Planning at PHC, Sub center, Community involment • Registes and Records. Outcome of Course. • 1391 candidates have passed the course till date. • These are registered with the Chhattisgarh Medical Board. • They are not allowed to practice independently. 

             In August 2008 it was decided to appoint them as doctors at the Primary Health Center


Results Availability: - 361/721 (50%) PHCs were managed by Paramedical staff in August 2008 all these now have RMAs.

Improved access to health services for poor population residing in the Villages Less distance to travel, hence reduced cost of healthcare better affordability


Increased Utilization of health facilities (PHCs)

Proper screening before referral of the patient reducing rudimentary case load in CHC/Dist. hospital Assist in implementation of all National and state level health programs

  • 􀂃 In case of any emergency situation, RMAs have to provide primary health care services and then refer
  • the patients to higher level of public hospitals based on the requirement.
  • 􀂃 Provide preventive health education and measures to attain good health.
  • 􀂃 Provide limited primary level treatment for some of the conditions.
  • 􀂃 Provide basic maternal and child health care, conduction of Delivery, Basic management of
  • complications of pregnancy and childbirth, Suturing of first degree Perineal tears.
  • 􀂃 Perform simple operative procedures - repair of small wounds by stitching, drainage of abscess; burn
  • dressing, applications of splints in fracture cases, application of tourniquet in case of severe bleeding
  • wound in a limb injury
  • 􀂃 Provide primary level treatment for 5 – 7 days only if the improvement is visible in the health of the
  • patient else they should refer the patient to the nearby CHC for further treatment.
  • 􀂃 Permission from the High Court and Supreme Court to dispense certain Over The Counter (OTC)
  • Drugs
  • 􀂃 Linkages with communities to increase the service delivery.
  • 􀂃 Regular meeting with the peripheral staff.
  • 􀂃 Follow up in treatment diseases initiated by Medical Officers of CHC and PHC
  • 􀂃 Follow up of all National Health Programs in Coordination with the BMO.

Availability of RMA opens new possibilities Because of availability of 400 women RMAs we are now implementing –Fixed day RTI\STI services through a lady doctor at PHC. At least 1 ANC by a lady doctor At the time of writing this case study, the political- administrator position is modified to see this model as offering a way forward to solve the problem of retention in rural areas. This is because of four factors- graduates have accepted this arrangement, PHCs vacancies have been greatly reduced , preliminary reports show patient and public satisfaction with the arrangement, and finally the professional resistance to this arrangement is muted, if not altogether absent. An evaluation is ongoing to test whether the professional skills they have and use is comparable with other alternatives and to formulate strategies of improving this. The preliminary reports are positive and the clinical gaps appear remediable in-service. Currently the Ministry of Health is also thinking of upgrading the Health Sub-centers to an independent, fully functional curative care unit in addition to the hither to preventive and health promotive roles like the one being implemented in China. In this context, RMAs are the best option to be placed in such Health Sub Centers in addition to the ANMs considering the cost factor and availability of such human resource in remote areas.

RURAL MEDICAL ASSISTANT IN CURRENT chhattisgarh government now created 741 regular post of Rural Medical Assistant and out of 741 post 593 post are full with PMHM docters as a rural medical assistant at primary health centers,And rest of PMHM docters working still in NRHM as a same post, some of than also working in community health centers also now a days they are like spine of chhattisgarh health facilities.

External Links cghealth.nic.in/.../chhattisgarh experience with 3-year.pdf http://www.indianexpress.com/news/3yr-medical-graduates-to-fill-rural-posts/500445 www.cghealth.nic.in

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