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The assistant medical officer in Sri Lanka: Mid-level health worker in decline

DOI:10.3109/13561820.2013.776023
Authors:
Vijitha De Silva at University of Ruhuna
Vijitha De Silva
Justine Strand de Oliveira at Duke University
Justine Strand de Oliveira
Mahinda Liyanage
Mahinda Liyanage
Mahinda Liyanage
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Truls Østbye at Duke University Medical Center
Truls Østbye
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Abstract

Abstract The history of Assistant Medical Officers (AMOs) in Sri Lanka can be traced back to the 1860s. Their training from the beginning followed an allopathic, 'evidence based' model. AMOs have played a key role in rural and peripheral health care, through staffing of government central dispensaries and maternity homes and may have contributed to Sri Lanka's favorable health outcomes. While there are currently approximately 2000 AMOs, their training course was discontinued in 1995. It was argued that the quality of care provided by the AMOs is substandard relative to that of physicians. The success, rapid expansion and integration of physician assistant programs into the US health care system have recently spurred other countries to introduce similar programs. This paper reviews Sri Lanka's move in the opposite direction, phasing out the AMO profession, without any research into their contributions to access to interprofessional primary health care and positive health outcomes.
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2013
http://informahealthcare.com/jic
ISSN: 1356-1820 (print), 1469-9567 (electronic)
J Interprof Care, Early Online: 1–2
!2013 Informa UK Ltd. DOI: 10.3109/13561820.2013.776023
The assistant medical officer in Sri Lanka: mid-level health worker in
decline
Vijitha De Silva
1
, Justine Strand de Oliveira
2
, Mahinda Liyanage
3
and Truls Østbye
2
1
Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka,
2
Department of Community and Family Medicine, Duke University Medical Center,
Durham, NC, USA, and
3
District Hospital, Kadugannawa, Sri Lanka
Abstract
The history of Assistant Medical Officers (AMOs) in Sri Lanka can be traced back to the 1860s.
Their training from the beginning followed an allopathic, ‘evidence based’ model. AMOs have
played a key role in rural and peripheral health care, through staffing of government central
dispensaries and maternity homes and may have contributed to Sri Lanka’s favorable health
outcomes. While there are currently approximately 2000 AMOs, their training course
was discontinued in 1995. It was argued that the quality of care provided by the AMOs
is substandard relative to that of physicians. The success, rapid expansion and integration of
physician assistant programs into the US health care system have recently spurred other
countries to introduce similar programs. This paper reviews Sri Lanka’s move in the opposite
direction, phasing out the AMO profession, without any research into their contributions to
access to interprofessional primary health care and positive health outcomes.
Keywords
Assistant medical officers, history of medicine,
mid-level health worker, physician
assistants, primary care, Sri Lanka,
workforce
History
Received 24 June 2012
Revised 14 January 2013
Accepted 10 February 2013
Published online 9 May 2013
Introduction
In Sri Lanka, the assistant medical officer (AMO) has played a
key role in the health sector since the island nation was a British
colony. A multi-ethnic country with a population of just over
20 million, Sri Lanka has a high literacy rate and very good
public health indicators relative to other middle income countries
(World Health Organization, 2012a). In 1995, Sri Lanka stopped
the training of AMOs. This report reviews the history of AMOs
in Sri Lanka and considers the discontinuance of the AMO in the
context of changing health policy, juxtaposed with the increasing
utilization of such resources globally.
Background
Although physician assistants (PAs) have been in existence in
the United States since the mid-1960s and many developed
countries including Canada, the Netherlands, Great Britain and
Australia (Hooker & Kuilman, 2011) have adopted the PA
model, antecedents to PAs can be traced back hundreds of years.
The AMO model found in former British colonies including
sub-Saharan Africa (Mullan & Frehywot, 2007) and Sri Lanka,
the practicante adopted by the Spanish in their colonies including
Puerto Rico, the feldshers in Russia and barefoot doctors in
China have all been cited as historical antecedents to the PA
(Strand, 2006).
PAs and their equivalents elsewhere were created as a direct
subordinate and extension to physicians and allowed to practice
medicine where physicians were unable or unwilling to serve.
They do not enjoy the prestige or income of physicians but may be
more likely, at least initially, to care for the poor in undesirable
areas (Hooker, Cawley, & Asprey, 2010). PAs have been found to
deliver high quality (Cooper, 2006), cost-effective (Cooper, 2001)
health care with high levels of patient acceptance and satisfaction
(Bureau of Health Professions, 1992). However, some physicians
are less than willing to cede jurisdiction to PAs, as found in a US
study where physicians lowest in the medical hierarchy were the
most resistant (Ferraro & Southerland, 1989).
Discussion
Historical and contemporary issues
In 1869, the British established an auxiliary medical service
in parallel to the medical service, with the main objective of
delivering health services to rural populations, especially to those
living in disadvantaged areas. The scheme for training AMOs
was formalized by Sir William Gregory (Governor of Ceylon
1872–1877) in consultation with Dr W. R. Kynsey, head of the
civil medical department at that time (Uragoda, 1993).
A medical school was established in the capital, Colombo,
in 1870. In 1877, Kynsey developed a secondary medical course
to train ‘‘medical practitioners’’ (initially called apothecaries)
who formed the backbone of the rural dispensary system. This
AMO training program consisted of 1 year at the medical college.
The curriculum included structure and function of the body
(anatomy and physiology), nutrition, biochemistry, pharmacology
and pharmacy, microbiology, parasitology, pathology, community
medicine, medicine, surgery, pediatrics, gynecology and obstet-
rics. The didactic year was followed by 6 months of clinical
training. AMOs with 8 years of practice experience were eligible
to become registered medical officers (RMOs) and practice
independently (Liyanage, 2004). With the establishment of the
University of Ceylon in 1942, education of physicians, receiving
the degree MBBS (the MD is a postgraduate degree in Sri Lanka,
usually including research and specialization) flourished. As the
number of physician graduates increased, matriculants to the
Correspondence: Justine Strand de Oliveira, Department of Community
and Family Medicine, Duke University Medical Center, DUMC 104780,
Durham, NC 27710, USA. E-mail: justine.strand@duke.edu
J Interprof Care Downloaded from informahealthcare.com by Duke University Serials Dept on 06/03/13
For personal use only.
AMO course gradually decreased, and since 1960, medical
graduates have outnumbered the AMOs. With the government’s
decision to discontinue the training of AMOs in 1995, the number
of physicians graduating from Sri Lanka’s eight allopathic
medical schools has increased even further.
For almost 150 years, the services of AMOs were an important
part of Sri Lanka’s health sector. Throughout this period, most
of the government central dispensaries and maternity homes
(approximately 380) distributed across the island were run by
AMOs and RMOs. In addition, some rural and peripheral
hospitals were also managed by them. Almost all the AMOs
currently in service are RMOs, with many having set up private
practices (about 1000) and operating with minimal physician
supervision (Liyanage, 2004). Despite the government now
depending more on graduate physicians to provide primary care,
including to those in medically underserved areas, the 950 RMOs
currently in government service continue to play a significant
role in the outpatient departments of district hospitals and
base hospitals (Liyanage, 2004). In addition to their duties in
the outpatient departments, AMOs working in rural and periph-
eral hospitals are on call and treat inpatients.
Current policy drivers and directions
In an era of increasing chronic conditions (World Health
Organization, 2012b) and a growing private sector delivery of
health care (Institute of Policy Studies of Sri Lanka, 2012), access
to effective interprofessional primary care has a significant impact
on health outcomes and costs. With the discontinuance of AMO
training and the eventual end of the occupation by attrition, it is
yet unclear whether physician distribution in Sri Lanka will reach
the same areas served by AMOs. The physicians’ associations
argue that enough physicians exist to provide access to care in
rural areas and therefore AMOs are not needed. They also argue
that AMOs do not provide the same quality of care as physicians,
though no objective evidence is available to support this claim.
The AMO association on the other hand, asserts that the real
motivation is to preserve the physicians’ dominant position in the
medical hierarchy (Liyanage, 2004).
Sri Lanka’s favorable health indicators relative to other
countries at a similar level of economic development may be
due in part to a well-developed public health system and the
availability of primary care, especially in rural areas (World
Health Organization, 2012b). For 150 years, AMOs provided
this care in remote areas and were the practitioners who staffed
outlying hospitals and outpatient clinics. There may be other
reasons that the service of AMOs improved health outcomes, as
access to care has social dimensions and is not just measured
in clinicians per square kilometer. Though little data is available
regarding AMOs, and because their numbers are in decline, their
impact may never be known.
Task shifting, the process of delegation whereby tasks are
moved, where appropriate, to less specialized health workers is
seen as an answer to the increasing need for human resources
for health care in both developed and developing countries. The
US is increasing its output and utilization of PAs, and other
developed and emerging countries are following suit. It may be
considered ironic that Sri Lanka is going in the opposite direction,
allowing the AMO model to decline by not continuing their
educational programs. The AMO in Sri Lanka seems on course
to be eliminated by attrition, without much consideration of how
the AMOs could be a part of an interprofessional health care team
of tomorrow and without any research into their contributions to
access to primary health care and positive health outcomes.
Acknowledgements
The authors wish to thank Virginia Carden, MSLS, AHIP for reference
assistance.
Declaration of interest
The authors report no declarations of interest. The authors alone are
responsible for the content and writing of the paper.
References
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2V. De Silva et al. J Interprof Care, Early Online: 1–2
J Interprof Care Downloaded from informahealthcare.com by Duke University Serials Dept on 06/03/13
For personal use only.
... Studies that have measured patient satisfaction with the provision of primary care have found that patients who received care from NPHWs were equally or more satisfied than those who received care from physicians [23][24][25][26]. In Chhattisgarh India, patients of Medical Officers and NPHWs reported similar levels of satisfaction, trust, and perceived quality, with scores of 84% for Medical Officers, 80% for AYUSH Medical Officers, and 85% for RMAs [27]. ...
... In Sri Lanka, the use of NPHWs has played an important role in rural healthcare through adequate staffing of public health facilities, plausibly contributing to its improved health outcomes [24]. In 1995, the NPHW on-job training was discontinued due a narrative that the quality of care provided by them, particularly the Assistant Medical Officers was substandard as compared to that of the physicians [24]. ...
... In Sri Lanka, the use of NPHWs has played an important role in rural healthcare through adequate staffing of public health facilities, plausibly contributing to its improved health outcomes [24]. In 1995, the NPHW on-job training was discontinued due a narrative that the quality of care provided by them, particularly the Assistant Medical Officers was substandard as compared to that of the physicians [24]. Regardless, the cause of their attrition was also contributed to the government's increasing dependence on physicians to provide primary healthcare, including to those in medically underserved and peripheral areas [24]. ...
View
... Task shifting is a well-recognized cost-effective model for providing healthcare worldwide and is used in a many lower-income countries as a means to expand the access of care in critically underserved areas. 16 Task shifting is defi ned by the World Health Organization (WHO) as the "a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers." 17 WHO, US Presidential Emergency Plan for AIDS Relief (PEPFAR), and the Joint United Nations Programme on AIDS (UNAIDS) endorse task shifting and have been working to develop global guidelines. ...
... A similar phenomenon was observed in Sri Lanka when the AMO training programs were suspended in 1995 without research into their contributions, particularly in rural areas. 16 One argument was that there was no longer a physician shortage in Sri Lanka so AMOs were no longer needed. This observation is not the case in Tanzania. ...
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Country health system profile: Sri Lanka. Development of the health system Retrieved from http:// www.searo.who.int/en/Section313/Section1524_10879.htm World Health Organization. (2012b) Trends in health status. Country health system profile: Sri Lanka
  • Jan 2012
World Health Organization. (2012a). Country health system profile: Sri Lanka. Development of the health system. Retrieved from http:// www.searo.who.int/en/Section313/Section1524_10879.htm World Health Organization. (2012b). Trends in health status. Country health system profile: Sri Lanka. Retrieved from http://www.searo. who.int/en/Section313/Section1524_10881.htm