Kabir Sheikh, Asha George (editors). Health providers in India: on the frontiers of change. New Delhi: Routledge; 2010. 355pp.

India’s health system is in a transitional phase and with the introduction of the National Rural Health Mission and the expanding medical education sector, there have been significant changes in the workforce. Healthcare workers, both in the public and private sector, are agents of change and play a critical role in achieving the health goals of the country. This book explores the different types of providers and their experiences.

The first part of the book deals with grassroots level healthcare workers who are often caught between the system and its users. As the foot soldiers of the system, they are often the most vulnerable and the most challenged. Asha George explores the complex dynamics of working in the community, the gender norms and vulnerabilities that women workers must contend with, how they negotiate within the system and the justifications they give for these negotiations.

Dileep Mavalankar and colleagues describe transformations in the role played by the auxiliary nurse and midwife (ANM) consequent to changes in policy and syllabus, the conversion of ANMs into “multipurpose workers”, and, above all, the lack of professional growth. All this has left ANMs a frustrated group within the health system. The authors call for a comprehensive approach aimed at improving training and professional growth and redefining the role of ANMs.

In the next chapter, Akhila Vasan and Jayashree Ramakrishna look at a more recent development in the form of voluntary counselling and testing centres (VCTC) in the Indian hospital setting. Counsellors employed in these centres face the difficult task of addressing gaps in the system while implementing the principles of rights and ethics upon which the centres are based. The authors conclude that we have failed to learn about human resource management in the health sector from our experiences with ANMs or rural health workers. They note that a policy providing a more supportive working environment and professional development for counsellors is essential if the programme is to achieve the desired results.

Rama Baru in her chapter explains how structural changes transformed the interactions of doctors in the public sector. The post independence era saw the middle class playing a more prominent role in the public sector. Government doctors have new attitudes, values and aspirations with growing commercialisation, economic transformation, consumerism and increasing competition from the private sector. The decline in the quality of government services can be attributed largely to the economic and academic demoralisation of government doctors.

Discussing the Indian health sector without talking about the private sector is like ignoring the elephant in the room. R Hess, S Sinha and P Marjara in this chapter describe the strategies employed by an international NGO that utilises the private health force to boost public health programmes. Public-private partnerships are already considered to be a viable option for the ailing public health sector in India, but, as the authors caution, strong regulations for the private sector are necessary.

Policy failures are often attributed to the lack of compliance from practitioners. Kabir Sheikh and John Porter explain the providers’ perspective of this gap: their roles, their priorities and the practical constraints that limit their compliance with government policies and programmes. They emphasise the importance of consensus, and of respect between policy makers and practitioners.

Venkatesan V in his section explains the political and power dimensions of the anti-reservation strikes held by medical students in 2006 which captured nationwide attention as they disrupted service delivery in many premier medical institutions in the country. The author criticises the soft approach that the judiciary took to doctors on strike and also urges the medical community to introspect on its inherent biases.

Madhura Lohokare and Bhargavi Davar give readers an insight into the role of indigenous healers, especially in the case of mental health ailments. It is common knowledge that the mental health services offered by our public health institutions are far from satisfactory. The lacuna is very often filled by indigenous healers whose come from the same socioeconomic background as the community and are also more accessible. Indigenous systems, even though not a replacement to government health services, enhance the knowledge and functioning of modern systems of medicine.

India has a rich history of traditional medicine. Unnikrishnan PM, Lokesh Kumar and Darshan Shankar explain the role of traditional orthopaedic practitioners, especially in rural health service delivery. Though institutionalisation is one way of recognising traditional practices, it carries the inherent danger of losing “experience-based and personalised aspects” of such care. The authors acknowledge that the 11th Five Year Plan with measures to strengthen traditional practices is a step in the right direction.

Family care providers play a significant role in the spectrum of healthcare, especially in a resource-poor setting like India. Shilpa Karvande and her colleagues explain the role of family caregivers in the scenario of HIV/ AIDS, a physically, emotionally and financially draining responsibility. Healthcare programmes, especially support programmes involving family support, will succeed only if there is a planned approach to address the needs of caregivers.

Sexual harassment is one of the most common stress factors that women health workers encounter in the work place. Paramita Chaudhuri in this chapter looks at different dimensions of such harassment, the support and redress mechanisms in place, and loopholes in these mechanisms. She concludes by noting the need to implement stronger monitoring mechanisms and put stricter regulations in place to prevent sexual harassment at the workplace.

In the final chapter Anagha Pradhan, Renu Khanna and Korrie de Koning elaborate on a programme on gender sensitisation of male multipurpose workers. There is a growing recognition of the role that men play in women’s sexual and reproductive health. This chapter gives us insights into the challenges and approaches of sensitising male multipurpose workers about gender, and the benefits that the system can reap from such an effort.

The book also contains poems by Gieve Patel, reflections of his career as a healthcare provider. He takes us through the world of a medical practitioner – the experiences, the pain, the doubts and, finally, the hope that drives the world of the patient and the provider.

Policies and programmes are the skeletons upon which entire health systems are built and survive. These policies are often based on expert group or international consultations and do not represent the most critical voice – that of the provider who interacts directly with users of the health system. There is a need to engage in consultations with sufficient representation from all sections of the community, including both providers and health seekers. The book under review is a significant effort to bring to light the many voices that are not heard in policy or programme documents.