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 Table of Contents  
POSITION PAPER OF THE INDIAN ACADEMY OF GERIATRICS
Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 176-179

Health workforce development for geriatric services in India


1 Assistant Professor, Department of Geriatric Medicine, Yenepoya Medical College, Mangalore, India
2 Ex-Principal, Professor, Department of Medicine, Dr S N Medical College, Jodhpur, India
3 Ex-Professor and Head, Department of Geriatric Medicine, AIIMS, New Delhi, India

Date of Web Publication24-Feb-2021

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-3405.310003

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How to cite this article:
Rao AR, Mathur A, Dey A B. Health workforce development for geriatric services in India. J Indian Acad Geriatr 2020;16:176-9

How to cite this URL:
Rao AR, Mathur A, Dey A B. Health workforce development for geriatric services in India. J Indian Acad Geriatr [serial online] 2020 [cited 2021 Apr 20];16:176-9. Available from: http://www.jiag.com/text.asp?2020/16/4/176/310003


  The Indian Academy of Geriatrics Top


The number of older adults (age 60 years and above) in India is projected to rise to 300.9 million by 2050. Providing health-care to this vulnerable population is complex, and requires an individualized approach. Geriatricians are physicians who specialize in comprehensive assessment and treatment of the conditions that affect older adults. The developed nations have recognised the shortage of Geriatricians and implemented measures to overcome this problem. It's estimated that one geriatrician is needed for 50,000 population, or 6,000 older adults aged 60 years and above. If India is to provide standard health-care for its growing older population, it is estimated that we need 27,600 Geriatricians for 138 crore population. Addressing the shortage of geriatricians is the need of the hour which can be solved by taking measures at various health-care system levels, education reforms and policymaking. These measures can include:

  • Training primary care physicians and internists.
  • Mid-career training of family physicians and general practitioners.
  • Mandatory addition of geriatric medicine in the medical curriculum
  • Incentives for institutes to implement geriatric medicine postgraduation programme.
  • Making geriatric medicine a mandatory department for medical colleges.


Through these measures, we can aspire to achieve the goal of healthy ageing and health for all.


  Introduction Top


Populations worldwide are ageing at a faster pace than in the past with an impact on almost all aspects of society. Global population ageing is a significant challenge and an opportunity to act by all countries. India is also witnessing a demographic transition. The population over the age of 60 years has tripled in the last 50 years, and it is projected to rise to 300.96 million by the year 2050.[1] This ever-increasingageing population puts immense strain on our country's health system due to the dual burden of non-communicable and infectious diseases. The World Health Organization (WHO) has defined Healthy ageing as developing and maintaining the functional ability that enables well-being in older age. The United Nations Decade of Healthy Ageing (202111-2030) is a concerted, catalytic and collaborative action initiated to improve the livesof older people, their families, and the communities in which they live. The goal of the Decade is to optimize older people's functional ability. The WHO Global strategy on human resources for health (Workforce 2030) aims to improve health, social and economic development outcomes by ensuring universal availability, accessibility, acceptability, coverage and quality of the health workforce through adequate investments to strengthen health systems, and implementation of effective policies at national levels.[2] The Ministry of Health & Family Welfare, Government of India, launched the “National Programme for the Health Care of Elderly” (NPHCE) during the year 2010 to address older people's health-related problems and improve their quality of life. One of the strategies of NPHCE is the development of the health workforce for geriatric services.


  Why Geriatricians? Top


Geriatric Care is a complex speciality. Older individuals differ from the younger ones in many ways, and these include heterogeneity, homeostenosis, different disease presentations, co-morbidities, and chronicity of diseases. Hence these older patients cannot be treated like their younger counterparts. And this is where geriatricians can help. Geriatricians are trained to treat the non-communicable disease and assess the unmet physical, psychological and social needs of the older individuals via comprehensive geriatric assessment. They are better qualified to manage multi-morbidity (presence of two or more diseases), assess and reduce unnecessary, invasive and often expensive investigations and decrease the harmful effects of high pill-burden. Geriatricians also play various roles such as acute assessment and intervention for older people with frailty, dementia, delirium and other mental health problems, and liaison with other services such as orthogeriatrics, geriatric-surgical models, oncology and palliative care.[3]A geriatrician can coordinate the care across all levels- home, community, long term care facilities, subacute care and acute care hospitals.


  Status of Geriatric Training and Health Workforce Need Top


WHO strongly advocates training all future medical doctors in the care of older people.WHO developed a study on Teaching Geriatrics in Medical Education (TeGeMe) to assess how geriatric medicine was being taught worldwide in the medical curriculum.[4] It included a national questionnaire enquiring about a national medical curriculum and the inclusion of geriatric medicine and a local questionnaire assessing geriatric training. The study showed that 53% of all countries had national regulations for medical school curricula. In 41% of the countries the curricula mention geriatrics in some way, 24% of all participating medicine schools had an independent unit for geriatric medicine. Among the high-income countries, 38% of the schools offer postgraduate studies in geriatric medicine, whereas only 7.5% of schools in economies in transition offer postgraduate studies. The reasons given for not teaching geriatric medicine were varied, the most cited reason was that geriatrics was not in the national curriculum (77%), the other reason cited (50%) was that “older people are not a priority issue”, followed by lack of interest from the medical school (27%). A study that reported the knowledge, attitude and perception of medical interns and postgraduates in Mumbai showed that both groups had a positive perception of the older patients needs. Still, the negative attitude towards ageing could stem from the inadequate knowledge imparted during the undergraduate medical curriculum[5].

Barriers to training the health workforce on gerontology and geriatrics include insufficiently qualified faculty/instructors, lack of funding, inadequate time build into the curricula, and poor recognition of the importance of such training.[6]

The concern that there isan insufficient number of geriatricians to meet the needs of their ageing population has been realised by developed countries such as United Kingdom[7], United States of America[8], Canada[9] etc., The American geriatrics society acknowledges that the number of geriatricians is projected to increase modestly between 2013 and 2025, but the demand will grow steeply. They also add that 30% of people 65 years and older need care from a geriatrician. Each geriatrician can care for up to 700 patients, translating to considerable demand for geriatricians[10].

The Royal College of Physicians (RCP) guidance recommends a minimum of one consultant geriatrician per 50,000 population.[7] A study from Texas found that they had one geriatrician per 5,132 older people, and indicated a severe shortage of board-certified geriatricians.[11] Though there is no universally accepted workforce defining as an adequate amount of manpower, an attempt was made in Australia to determine an adequate, quantifiable geriatrician full-time equivalent (FTE) required to run geriatric medicine comprehensively.[12] They suggest 0.4 FTE geriatrician time per 10,000 people or 2.0 FTE per 50,000 head of population may afford the ability to provide Australian regions with comprehensive outpatient and inpatient geriatric services.

According to the 2011 census, the proportion of older people in India was 8.3% of the total population, increasing to 10% by 2020. With the total population of 138 crores, an estimated 13.8 crore people above the age of 60 are currently living in India. From this data, we can estimate the number of Geriatricians required. As per the RPC (UK) recommendations, if we consider one geriatrician per 50,000 unit population, we need 27,600 geriatricians for 138 crore population.

And according to the American Geriatric Society (AGS), 30% of the older population requires geriatric care. Thus 4.14 crore older people in India will require geriatric care. Further, one geriatrician can cater to a maximum of 700 older patients. Therefore we will need 59,000 geriatricians in India.

The response of Government of India - NPHCE falling short of the need

The National Programme for Health Care of the Elderly (NPHCE) envisions to provide accessible, affordable, and high-quality comprehensive and dedicated care services to an ageing population, creating a new “architecture” for ageing, to build a framework to create an enabling environment for “a society for all ages” and to promote the concept of Active and Healthy Ageing[1]. It is imperative to increase the number of physicians who can provide such comprehensive care to reach these goals. NPHCE proposes to overcome the shortage of trained medical and para-medical professionals in geriatric medicine by in-service training to the health workforce using standard training modules prepared with the help of medical colleges and regional institutions. The postgraduate courses in geriatric medicine will be introduced in Regional Geriatric Centres (RGCs) for which additional teaching and supportive faculties are provided to these institutions.

During the 12thfive year plan, it was proposed that 12 more medical colleges will be added for setting up of Regional Geriatric Centres in addition to the 8 RGCs proposed during the 11th five-year plan. These RGCs would need one professor, two assistant professor and four senior residents/medical officers. Assuming that all the RGCs become functional with adequate staff, we would still have only 120 geriatricians, far below the minimum requirement.

Proposed interventions to ensure a sustainable and appropriately trained health workforce

With a growing need for physicians trained to care for older adults, few measures can be taken.

Since a majority of older adults are treated at primary care level, and family and general practitioners provide the largest proportion of non-hospital-based care. All health-care professionals need the right competencies to care for ageing populations; therefore, they need to be trained in gerontology and geriatrics.

Medical training must include gerontology and geriatrics at undergraduate and postgraduate level.

Existing health and medical staff may need in-service training and continuing medical education for comprehensive healthy ageing assessments and integrated management of complex health care needs. All health and medical curricula should include core geriatrics competencies.

Besides training the primary care health professionals, there is a need to have a critical mass of geriatricians to see and treat complex cases. These geriatricians would perform academic and practice roles. They would serve as consultant specialists in managing complex geriatric problems and maintaining ongoing responsibilities for some subset of older patients. There isa startlingly low number of geriatricians in our country, against the need of over thousands of them. This could be achieved by starting a postgraduate course on Geriatrics at all medical schools.

Innovative ways to use existing health workforce with role modification to play a more active part in older people's care must be considered. Nurses or other health workers can play an important role by using their skills to complement physicians in crucial tasks such as assessment, treatment management, self-management support, and follow-up care.

Strategies to strengthen geriatrics training for physicians

The plan to strengthen geriatric training must focus on two levels: the overall strengthening of the geriatric medicine movement and creating specific strategies for various medical education levels. We could adopt the recommendations provided in the Shortage of Health Care Professions Caring for the Elderly: Recommendations for Change.

It stated that to achieve the goal of increasing the number of trained academic geriatricians there is a need to provide incentives for physicians to choose a career in geriatric medicine, offer more excellent opportunities in clinical research training, increase geriatric content of undergraduate and postgraduate medical programs, improve attitudes towards geriatrics by medical students, staff and academic, administrative leaders and develop public policy initiatives which will mandate increased geriatrics training and facilitate the development of clinical programs targeting older persons.

Establish and implement grants to medical schools that implement mandatory basic science and clinical curriculum components on ageing. Similar awards to residency programs for the addition of compulsory training in geriatrics.

Some other strategies which can be used are, higher salaries for trainees and geriatrics fellows, low-interest loans for the development of academic careers in geriatric medicine, improved reimbursement for interdisciplinary care of geriatric patients, loan forgiveness program for physicians entering training in geriatric medicine, training programs aimed at increasing and fostering research skills of geriatrics fellows.

Certification of Geriatricians could be intended to provide a means by which family physicians and internists can obtain recognition of their expertise in geriatric medicine. It could be executed by a 1-2 year fellowship course in advanced geriatric medicine from the National Centre of Ageing, Regional Geriatric Centres and institutes with established Department of Geriatric Medicine.

Recommendations

A well-planned infrastructure to support older people's care can be developed through well designed educational programmes in geriatrics and gerontology.It is essential to acknowledge that while government policy may have contributed to the expansion of the number of geriatricians in the country, the ongoing changes in the NMC have the potential to alter the landscape dramatically over the coming years. Adding more years to life can be a mixed blessing if it is not accompanied by adding more life to years.

Key Interventions to ensure a sustainable and appropriately trained health workforce include:

  1. Training primary care physicians and internists,
  2. Mid-career training of family physicians and general practitioners,
  3. Mandatory addition of geriatric medicine in the medical curriculum,
  4. ncentives for institutes to implement geriatric medicine postgraduation programmes,
  5. Making geriatric medicine a mandatory department for medical colleges.


Through these measures, we can aspire to achieve the goal of healthy ageing and health for all.

Acknowledgment

We acknowledge invaluable inputs from Dr. Alka Ganesh, Dr B Krishna Swamy, Dr I S Gambhir, Dr Prabha Adhikari, Dr G S Shanthi, Dr Surekha V and Dr Ashish Goel.



 
  References Top

1.
National Programme for Health Care of the Elderly (NPHCE) | Ministry of Health and Family Welfare | GOI [Internet]. [Last cited 2021 Jan 05]. Available from: https://main.mohfw.gov.in/major-programmes/other-national-health-programmes/national-programme-health-care-elderlynphce.  Back to cited text no. 1
    
2.
WHO | Global strategy on human resources for health: Workforce 2030 [Internet]. WHO. World Health Organization; [cited 2021 Jan 24]. Available from: http://www.who.int/hrh/resources/pub_globstrathrh-2030/en/.  Back to cited text no. 2
    
3.
Oliver D, Burns E. Geriatric medicine and geriatricians in the UK. How they relate to acute and general internal medicine and what the future might hold? Future Hosp J. 2016 Feb; 3(1):49–54.  Back to cited text no. 3
    
4.
WHO | Geriatrics and Medical Education [Internet]. WHO. World Health Organization; [cited 2021 Jan 7]. Available from: https://www.who.int/ageing/projects/tegeme/en/.  Back to cited text no. 4
    
5.
Subramanyam. Should undergraduates be introduced to geriatric training? A pilot study on knowledge, attitude, and perception in medical interns and postgraduate residents from a tertiary care hospital [Internet]. [cited 2021 Jan 10]. Available from: https://www.anip.co.in/article.asp?issn=2588-8358;year=2018;volume=2;issue=1;spage=33;epage=40;aulast=Subramanyam.  Back to cited text no. 5
    
6.
WHO | Health workforce for ageing populations [Internet]. WHO. World Health Organization; [Last cited 2021 Jan 24]. Available from: http://www.who.int/ageing/publications/health_workforce_ageing/en/  Back to cited text no. 6
    
7.
Fisher JM, Garside M, Hunt K, Lo N. Geriatric medicine workforce planning: a giant geriatric problem or has the tide turned? Clin Med Lond Engl. 2014 Apr; 14(2):102-6.  Back to cited text no. 7
    
8.
Hirth VA, Eleazer GP, Dever-Bumba M. A Step toward Solving the Geriatrician Shortage. Am J Med. 2008 Mar 1;121 (3):247–51.  Back to cited text no. 8
    
9.
Madden KM, Wong RY. The Health of Geriatrics in Canada —More Than Meets the Eye. Can Geriatr J. 2013 Mar 4;16(1):1-2.  Back to cited text no. 9
    
10.
Geriatrics Workforce By the Numbers | American Geriatrics Society [Internet]. [Last cited 2021 Jan 5]. Available from: https://www.americangeriatrics.org/geriatrics-profession/about-geriatrics/geriatrics-workforce-numbers.  Back to cited text no. 10
    
11.
Sumaya CV, Opara CM, Espino DV. The geriatrician and geriatric psychiatrist workforce in Texas: characteristics, challenges, and policy implications. J Aging Health. 2013 Sep; 25(6):1050-64.  Back to cited text no. 11
    
12.
Commerford T. How many geriatricians should, at minimum, be staffing health regions in Australia? Australas J Ageing. 2018;37(1):17-22.  Back to cited text no. 12
    




 

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