The physician assistant (PA) profession began in India in 1994 when Dr. Cherian established the first PA program with 14 students after being inspired by the PA program in Alabama. The profession started in cardiology and cardiac surgery due to a need for specialized healthcare workers. It has since expanded to many medical specialties and universities across India. While PAs have made significant contributions, challenges remain such as a lack of government licensure, standardized curriculums, and national certification. However, there are now efforts to expand PAs into primary care to help address India's shortage of rural primary care providers and growing burden of chronic diseases.

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PAs in India started out in the cardiology specialty.
Photo courtesy of Ebin Abraham, PA.
Marie Meckel, PA-C, MPH
November 25, 2015
PAs in India expanding from specialty areas to
primary care
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Ebin Abraham, PA, explains how the Indian PA profession began in cardiology and is now
starting to expand into primary care to help meet rural health needs.
Listen to the Podcast: PAs in India expanding from specialty areas to primary care
The physician assistant (PA) profession started in India
20 years ago and has been going strong ever since.
However, unlike the development of the PA profession in
other countries, India's physician assistant program
was first developed in a specialty field and is only now
trying to expand into primary care. Many countries
develop midlevel healthcare provider programs out of a
need to increase access to primary care; the
development of the PA profession in India is unique in
that it started in a specialty field (cardiology and
cardiac surgery). The PAs in India have many
challenges, but they have achieved some amazing
accomplishments. Indian PAs can be found in many
areas of medicine. I had the privilege of speaking to Ebin Abraham, PA, who specializes in cardiac surgery. Below is a
synopsis of our conversation.
Listen to the podcast
The history
00:00 -24:20

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The beginnings of the PA profession started in India in 1994. Its development was inspired by K. M. Cherian, MD, who
had trained in cardiac surgery at the University of Alabama. In the 1970s, Dr. Cherian worked under John W. Kirklin,
MD, who was a pioneer in the development of one of the earliest American Cardiac Surgical PA programs, and it was
there that Dr. Cherian learned about the PA profession.
When Dr. Cherian returned to India, he wanted to develop this same cadre of healthcare professionals. India needed
highly specialized healthcare professionals in fields such as cardiac surgery. Junior doctors were previously expected to
fill this role; however, they were not a good fit. According to Mr. Abraham, junior doctors, who have bachelor's degrees
in medicine or surgery, receive only minimal training in specialty fields. They also cannot be relied on as a regular source
of workforce because they often go on sabbaticals to prepare for competitive higher education entrance exams. So, at any
given time, there was a dearth of experienced hands in many areas of health care.
Mr. Abraham said that the large surgical patient panels also contributed to the need for another tier of healthcare
professionals in surgery.
To Dr. Cherian, developing a PA program seemed like a natural solution to the specialty healthcare provider shortage. In
Alabama, he witnessed firsthand how effectively PAs filled in the gaps that existed in health care. The other obvious
advantage to introducing the PA position is that they only require 3 years of training versus the 6 years it takes to train
medical doctors. There is also less chance of losing these professionals to “brain drain,” in which doctors and nurses
leave their home country to work abroad.
The beginning
Dr. Cherian began the first PA program in 1992 with only 14 students. These students were trained in the hospital, and
after 2 years of training, they received a postgraduate diploma. One year after the program began, it was upgraded to a
postgraduate degree affiliated with the Birla Institute of Technology and Science in India. After a few years, it was
changed to a 4-year bachelor of science degree.
According to Mr. Abraham, the profession spread because PAs proved to be such great assets to the work of cardiologists
and cardiac surgeons. When cardiac surgeon trainees completed their training, they brought some PAs to their new
hospital sites. Mr. Abraham noted that PAs are found mostly in Southern India where the profession began.
The PA profession has experienced significant growth and educational upgrading since its inception in 1992. In 2004,
Amrita University in Kochi, Kerala, began a master's degree PA program. In 2012, 10 universities offered PA programs at
47 institutions in India. As of 2014, more than 1,000 PAs have graduated from these programs. The success of the
transformation from a hospital-based program to a degree that is embraced by many Indian universities should not be
understated; PAs in other countries have had a very rough road from conception to acceptance.
Challenges
When I asked Mr. Abraham about the challenges that Indian PAs face, he told me that though the profession is not new, it
still lacks some essential elements that cement it in the healthcare system. There is no government licensure or
government council that recognizes PAs. The title of PA is not protected, which means that any type of professional
assistant in a hospital can technically have the title of PA. This has the potential to spoil the reputation of formally trained
PAs.
The curriculums across the different universities are not standardized, and there is no national licensing exam for PAs
who graduate. This can lead to substandard programs and a certain degree of uncertainty for these professionals. Mr.
Abraham said that this uncertainty has led many PAs to migrate to other fields or to pursue higher degrees in other
countries. He also said that the profession is still somewhat unknown to patients and medical organizations.

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Despite the challenges that PAs face, there are plans to expand these professionals into primary care. The educational
model for Indian PAs is similar to that of the American PAs, where students receive training in general medicine. This
focus on general medicine will serve as good preparation for PAs to transition into primary care.
The need for primary care in India is immense, and the country has to deal with many healthcare challenges India. India
is the second-most populous country in the world and has a double burden of communicable and non-communicable
disease. Although health status has improved in India, many challenges remain. In 2012, life expectancy was 66 years,
and infant mortality rate was 43.8 per 1,000.
India is showing signs of increased rates of non-communicable diseases. According to the WHO report, the rate of
elevated blood glucose was 11.1%, and the rate of hypertension was 22.6% for women and 23.1 % for men.
There are public health center facilities available, but they are overcrowded and cannot service everyone. The general
population lacks awareness of health issues, and many people are unaware of which disease conditions warrant medical
care. Many Indians do not recognize the importance of treating and controlling chronic diseases, such as diabetes and
hypertension. They present to clinics only at the end stages of these diseases, which makes it more challenging to deal
with these conditions as a whole.
Compared with other countries, fewer people in India have medical insurance; 75% of the Indian population pays for
healthcare service out-of-pocket. Because the out-of-pocket cost of care is so high, many families tend to ignore the
health care needs of their elderly and female family members.
Education
PA programs are usually a 3-year, bachelor's degree level program with an additional 1-year internship in a chosen field.
The university-based program accepts students who have graduated from the high secondary level. The programs'
curriculums concentrate on general medicine. However, because the program was developed at an institution that
specializes in cardiovascular surgery, many PA graduates end up working in a specialized medical field.
Work environment
According to Mr. Abraham, Indian PAs do not only work in outpatient and inpatient settings, but they are also found in
many non-clinical fields such as hospital information systems, hospital administration, and clinical research. Most PAs,
however, work in highly specialized fields of medicine. There are 14 specialty areas, which include cardiac surgery,
orthopedics, gastroenterology, plastic surgery, and neurology. Most PAs work in private institutions because their
profession is still not recognized by the government.
I left it to Mr. Abraham to describe what he does on a day-to-day basis as a PA. He works at the Metro International
Cardiac Center, which is the first and largest exclusive cardiac specialty hospital in Kerala. He works not only in a
clinical arena, but also in administration where he plans admissions, schedules surgeries, and does clinical research.
Mr. Abraham's clinical work consists of hospital rounds in the medical wards and in the ICU, educating patients and
families, and acting as a go-between for the surgeon and other physicians. In surgical work, he serves as first assistant in
all adult and pediatric surgeries, and he harvests radial arteries and saphenous veins for bypass surgery.
Mr. Abraham also is actively involved in the Indian Association of Physician Assistants, where he is the joint secretary
and general secretary for the Kerala state branch.
Despite the challenges that lie ahead, Mr. Abraham is optimistic about the future of the PA profession. He is particularly
excited that India's government has begun to look into integrating PAs into primary care settings.

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The history of the rural primary health care provider in India
There have been previous attempts to develop a primary care practitioner in India, and there has been a lot of opposition
in response. Past developments of the PA profession and similar positions were meant to address the shortage of primary
care providers in rural areas. One report estimates that 26% of doctors serve in rural areas, yet 72% of people in India
live in those rural parts of the country.
Although this shortage well known, India has had a difficult time developing a solution. One of the many challenges of
developing a workforce that will work rurally is that there is no guarantee that the intention of having graduates work in
rural locations after graduation actually occurs. Up until 1947, a cadre of healthcare practitioners referred to as Licentiate
Medical Practitioners were trained to work in rural areas. These professionals trained for 3 years, and two-thirds of this
group ended up working in rural areas. This was a fairly high rate, and it seemed like these practitioners would be the
solution to the needs of rural populations.
In 1943, the Indian government established the Bhore committee to address public health needs. The committee made
many important changes, such as establishing health centers throughout India and integrating prevention into the
healthcare system.
The Bhore committee reevaluated the role of Licentiate Medical Practitioners, ultimately deciding to replace them with
so-called basic doctors. These doctors would be given a basic education, which the committee asserted would prepare
them for work in rural areas.
Despite dissent, the Licentiate Medical Practitioner profession was phased out. The introduction of the basic doctor,
however, did not work out – these doctors did not end up working in rural areas.
The basic doctor curriculum was similar to a Western model, which resulted in most of these doctors working in a
specialty instead of primary care. Many of these doctors worked in urban areas or abroad.
In 2001, the idea of rural medical assistants (RMA) was proposed in an attempt to aid Chhattisgarh, one of the poorest
states in India that was in a health crisis. RMAs would receive 3 years of training: 2 years of coursework and a 1-year
internship focusing on working in rural areas. RMAs would provide primary health care, pediatric health care, conduct
deliveries, manage complicated pregnancies, and perform simple surgical procedures. A specific RMA position was
created to ensure that health centers had female practitioners as well as male practitioners.
Six colleges started adopting RMA programs and admitted approximately 150 students. However, political opposition
forced the profession to change its name and the type of certification granted by the program. The experiment that started
in Chhattisgarh will be expanded to other parts of India.
Mr. Abraham's message for the world
Mr. Abraham wants the world to know that PAs in India are doing some amazing work and are a great asset in many
specialty medical fields. India wants to be included in the international arena of PAs. With help from the rest of the
world, they can overcome many of the challenges they face.
Marie Meckel, PA-C, MPH, is a physician assistant who works in Western Massachusetts. She spent a year in South
Africa at Walter Sisulu University, where she taught clinical associates. Marie has spent the last year interviewing PAs
and NPs, their international equivalents, and American PAs and NPs working abroad.
Podcast produced by Rich Anderson, Web Producer.

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