Evolution of Occupational Therapy Practice in India: An Overview of the Historical Foundation and Current Practice
This article provides an overview of occupational therapy practice in India by discussing the inception and development of the profession, the educational system, the credentialing process, remuneration, types of research produced in India, and the challenges that Indian occupational therapists face because there is no central council.
Data for this conceptual review came from official government documents, the World Federation of Occupational Therapists, the Indian Journal of Occupational Therapy, and the All India Occupational Therapists' Association.
There are approximately 5,000 occupational therapists in India. Most are employed in the private sector in hospitals, special schools, rehabilitation clinics, home health systems, subacute clinics, and nongovernmental and nonprofit organizations. India has more than 21 million disabled individuals and an increasing need for health care and rehabilitation services. In addition, India has more than 21 undergraduate and 6 graduate occupational therapy educational programs that are accredited by the World Federation of Occupational Therapists.
To increase the efficacy of occupational therapy, practitioners must build and promote culturally relevant services that promote values of justice, peace, equality, cultural relevance, meaning, and advocacy. [Annals of International Occupational Therapy. 2019; 2(3):141–148.]
The profession of occupational therapy (OT) in India has gained visibility and prominence over time because of the increase in awareness of disabilities and accessibility, internationalization, and economic growth as well as the development of government policies that support the inclusion of people with disabilities in education (All India Occupational Therapists' Association [AIOTA], 2016; Mani, 2011). Also, legislation by the Indian government through the Right to Persons with Disabilities Act (2016) and the Mental Healthcare Act, 2017 (Gazette of India, 2017) has supported progress in the field of disability and rehabilitation through recognizing disabilities, outlining care plans, increasing awareness of the involvement of health care professionals, and increasing opportunities for occupational therapists.
This article provides an overview of OT practice in India by discussing the inception and development of the profession, the educational system, the credentialing process, remuneration, types of research produced in India, and the challenges that Indian OT practitioners face because of the lack of a central council (Srivastava & Bajpai, 2015). Potential answers to challenges are provided to help readers from other backgrounds to understand and replicate these solutions if appropriate.
Inception of Occupational Therapy in India
The emergence of OT as a profession in India is associated with important historical events, including wars that not only paved the way for its development but also embedded its roots in Western culture (Lim & Duque, 2011, p. 104). In 1947, a newly independent India spurred the growth of the health professions, including OT.
Ms. Kamala V. Nimkar (birth name, Elizabeth Lundy), an American philanthropist, was deeply motivated to contribute to the welfare of Indian society. After marriage, Ms. Nimkar moved to India and decided to develop an educational program based on the knowledge that she acquired from the United Kingdom. Once the school that she built grew into a mainstream educational institution, accommodating 1,500 students, she decided to rigorously improve the health care system. It was around this time that she discovered OT as a profession when she read an article by Helen Willard about OT. She immediately realized the potential of this profession and the effect it could have in the context of Indian health care. She was motivated to understand more about this profession and to explore the opportunities it presented (AIOTA, 2018). She completed her education at the Philadelphia School of Occupational Therapy and founded the profession in Mumbai (previously Bombay) in 1950 at Seth G.S. Medical College and K.E.M. Hospital with the support of Dean Dr. Dyagude. Because of its growth as an occupation, OT was integrated into the health care system by the municipality after a year (AIOTA, 2016). The first OT certificate course in Asia was developed in 1950 and accredited by the World Federation of Occupational Therapists (WFOT) in 1952. In 1967, two more diploma courses were developed and were affiliated with Bombay University, and the first master's degree program was developed in 1979 (AIOTA, 2016; Mani, 2011).
India was also a member of the Participatory Commission in 1952 and hence became a founding member of the WFOT. The AIOTA, which is the voluntary national association for OT, was formed in 1952. Ms. Nimkar played a fundamental role in its formation and also served as the first president (AIOTA, 2016; Mani, 2011). Another notable name in contemporary Indian OT is Mrs. Aruna Tole, who pioneered rehabilitation services by developing innovative and economical assistive devices and timely restorative and compensatory interventions for the management of cancer and leprosy (Hansen's disease), which causes permanent deformity and shortening of limbs (Mumbai Branch of AIOTA, 2013).
Current State of Occupational Therapy in India
According to the WFOT Human Resources Project 2016 (WFOT, 2016b), there are approximately 5,000 practitioners of OT in India; of these, 3,500 are registered with the AIOTA. Hence, there is an acute shortage of qualified occupational therapists in India, with an approximate ratio of therapists to total population of 1:1,000,000 (Office of Registrar General & Census Commissioner, 2001; Samuel & Jacob, 2017). Further, many occupational therapists leave to pursue professional opportunities in other countries, further reducing the number of qualified professionals (Chandra, 2010). Because of this skewed ratio of therapists to patients, the quality of care provided and the access to OT services in India may be markedly dissipated (Chandra, 2010). This shortage of qualified OT practitioners is countered by the presence of technicians from the Rehabilitation Council of India (Rehabilitation Council of India, 2018). Although the Rehabilitation Council of India is a governmental body that regulates and standardizes rehabilitation in India, the education administered by this body is at a perfunctory diploma level, which requires a maximum of 2.5 years of education (Rehabilitation Council of India, 2018). Hence, these programs do not provide students with comprehensive professional knowledge and skills (AIOTA, 2018). Thus, lack of a comprehensive understanding of the various aspects of therapeutic interventions limits the ability to provide optimal care (Ministry of Health & Family Welfare, 2019).
The lack of awareness of OT as a rehabilitative profession increases the challenges faced by Indian practitioners. A national regulatory body is needed to improve the current state of OT in India with evidence-based strategies to advance education, practice, and research (Shi, Howe, Hinojosa, & Yang, 2018).
A total of 57 OT programs have been identified by the WFOT (2019) in India, and of these, 21 undergraduate and 6 graduate OT educational programs are currently accredited by the WFOT (AIOTA, 2016). The rest of the programs (n = 30) are not currently accredited because they have been discontinued and replaced by advanced programs (e.g., diploma programs have been replaced by degree programs). A similar change has been witnessed in the Swami Vivekanand National Institute of Rehabilitation and Training in Odisha, which had an undergraduate program (3.5 years) that has been replaced with a 4.5-year bachelor's program (WFOT, 2019). The undergraduate programs require 4.5 years of study and supervised fieldwork (Maharashtra University of Health Sciences, 2002) in addition to completion of an individual research project. Graduate programs can be completed in 3 to 4 years and enable students to undertake specialized practice-based inquiry (Maharashtra University of Health Sciences, 2002). During this tenure, graduate students take up teaching and supervisory fieldwork roles (King Edward Memorial Hospital, 2017).
In India, OT education is deeply embedded in medicine. Education is developed in medical schools, and modules heavily embed these concepts (Maharashtra University of Health Sciences, 2002). It is crucial to have a basic knowledge of medicine to aid OT practice (Lim & Duque, 2011). However, there is an acute gap between medicine and the core concepts of OT, which include understanding the uniqueness and complexity of occupations from an Indian vantage point, cultural sensitivity, the benefits and challenges of participating in specific occupations that are exclusive to the Indian cultural and societal context, and strategies that enhance and promote occupational performance despite the complex cultural and societal dynamics (Radic & Klepo, 2017; WFOT, 2016a). Further, in Indian OT education, there is a void between “performance skills” and “knowledge.” The OT curriculum targets the knowledge end of the spectrum, but little emphasis is placed on transitioning these concepts to actual practice, or “know-how” skills. Hence, there is an urgent need to develop modules that concentrate on building attitudes, proficiencies, skills, outcomes, capacities, and accomplishments to allow OT practitioners to function as competent professionals (Ministry of Health & Family Welfare, 2019; Shi et al., 2018). Inclusion of important skills, such as critical thinking and reflexivity, strengthens the Indian OT curricula and helps students to develop stronger professional identities (Ministry of Health & Family Welfare, 2019; Radic & Klepo, 2017; Tolvett & Levia, 2017).
To standardize and regulate OT education in India, the AIOTA has developed a separate body, the Academic Council of Occupational Therapy (ACOT). The goal of the ACOT is to radically advance OT educational standards by improving the accreditation process of local educational institutions (AIOTA, 2016). Using the WFOT minimum standards as a scaffolding, this body outlines, formulates, and amends current educational requirements to accredit new and existing OT schools across the country by setting regulations to admit new students, monitor universities, facilitate renewal of accreditation standards, and monitor the activities of schools through annual reports (AIOTA, 2018). However, the WFOT educational standards must be tailored to include occupations that are exclusive to the Indian context. Although it is crucial to maintain an occupational focus in the educational curricula, it is also vital to integrate the nature and complexities of Indian occupations and accommodate cultural nuances to enable students and new graduates to provide optimal service. An important consideration is the Indian caste system and its influence on Indian occupations, occupational performance, and engagement. The caste system is a rigid, immovable societal system that classifies Indian people based on familial occupation at birth. At the top of this chain are Brahmins, who traditionally have enjoyed access to opportunities and occupations that enabled them to hold positions of authority and privilege. The people at the bottom are Shudras and the untouchables, who were conventionally forced into “unclean” occupations, such as cleaning, scavenging, and tanning leather (Smith, 1994). Because this system is such an integral component of the Indian societal, political, and fiscal ethos, OT practitioners in India must understand this dynamic and ever-evolving structure to better integrate concepts of Indian occupations, self-care, leisure, occupational performance, and engagement, thus increasing the visibility of OT and improving its integration into Indian society (Murthi & Hammell, 2018).
However, achieving this vision of OT education will be possible only with the formation of a national body that is recognized by public universities nationwide. Although the ACOT oversees national OT education, this body is autonomous because it is not a component of the Ministry of Health & Family Welfare (2019) and hence does not have absolute jurisdiction over Indian educational policies and practices (AIOTA, 2018). However, autonomous institutions can be governed by the ACOT alone, and changes are already visible in the education provided by these bodies. These institutions evidently embrace interprofessional educational approaches, research, and compelling clinical experiences (Manipal Academy of Higher Education, 2018).
Because the quality of OT education is a prerogative of ACOT, crucial transformations are needed in the way that knowledge is imparted. A review of the Indian health care system from the past 5 years noted that students from medical courses preferred problem-based learning and integrated knowledge dissemination instead of knowledge-heavy didactic pedagogy (Papanna et al., 2013). Chacko (2013) emphasized that didactic educational delivery rarely stokes students' inner curiosity, enabling them to think critically or engage in self-directed learning. Even the global OT community has recognized the importance of incorporating critical and reflexive thinking into the educational system to enable assimilation of information from various viewpoints to provide client-centered, relevant, and evidence-based services (Tolvett & Levia, 2017). The introduction of novel simulated and actual problem-solving scenarios can help to replace the knowledge-heavy didactic pedagogy with an approach that promotes clinical problem solving (Chacko, 2013; Federation of Indian Chambers of Commerce and Industry, 2013).
Further, developing a reflexive curriculum that promotes critical thinking and reasoning will enable students not only to understand the nuances of Indian occupations and societal constructs but also to tailor interventions to address Indian occupations (Ministry of Health & Family Welfare, 2015–16). The educational system must consider the collectivist, interdependent values of India while examining Indian occupations and activities to build modules that enable their exploration in a comprehensive and evidence-based manner. Also, the assessment system must evolve from the current use of semiannual or annual examinations to tests that evaluate both “know-what” and “know-how” skills to determine how students are using knowledge to guide clinical decision making (Ministry of Health & Family Welfare, 2019).
To build an OT educational system with a reflexive, current, and evidence-based curriculum that incorporates critical thinking, there is an urgent need to build a national body of experienced educators with clinical and research expertise to modify existing programs and formulate new modules that promote lifelong student engagement (Santos, 2017). Incorporating structures that monitor professional development through mandatory certification systems with tangible benefits, such as monetary increases or professional growth, will ensure the commitment of Indian clinicians and students to stay abreast of current global practice. Further, building higher education programs that offer doctoral degrees will also improve the expertise of OT professionals in India, as Radic and Klepo (2017) found in Croatia. Another strategy to align Indian educational programs to the global educational system is by forming alliances with established international universities (Lim & Duque, 2011). This can help the Indian educational system to adopt values from the social care model that is approved and assimilated by OT in other countries. An example of this approach is the program described by Lim and Duque (2011) that enabled students to participate in cross-cultural immersion modules in different contexts. Programs at Curtin University and other universities in the United Kingdom, Hong Kong, and China (Lim & Duque, 2011) enabled students from an Asian context to participate in a diverse ethos to learn crucial OT values, such as cultural awareness, in addition to service delivery and distinct clinical perspectives. Indian students can participate in immersive techniques to enable them to understand practice from different vantage points, boosting both interest and proficiency in critical and reflexive thinking, evidence-based practice, lifelong learning, and advocacy.
The ACOT has outlined a two-pronged approach to refine the Indian OT educational system. The first step is to target the educational structure, curriculum, and teaching strategies, and the second step involves research and building evidence (AIOTA, 2018). Building local evidence requires meticulous effort from the ACOT and a potential national association because it entails dissemination of knowledge to search, locate, critique, and create literature (Santos, 2017). The ACOT offers workshops, fellowship programs, online courses, webinars, conferences, continuing education opportunities, and regulation of the Indian Journal of Occupational Therapy.
Although OT practitioners in India regularly use online modules and webinars for professional development, the Indian Journal of Occupational Therapy has elected a new editorial team to improve the quality and structure of the journal by revising author and reviewer guidelines, developing policies and ethical standards, and building international viewership through indexing in international databases (AIOTA, 2018).
A review of articles published in the Indian Journal of Occupational Therapy between 2005 and 2014 showed that 52% of the research focused on quantitative strategies for determining the effectiveness of treatment (Rege & Acharya, 2017; Shetty, 2011). Although quantitative research is fundamental for identification of high-quality treatment with optimal effectiveness, equal importance needs to be given to qualitative research methods because some aspects of naturalistic research, such as subjective experiences and sociocultural dynamics, can be explored only through qualitative methods (Rege & Acharya, 2017). Indian practitioners must engage in research that includes individual experiences and reflections to build an empirical knowledge base that reflects the Indian social and cultural ethos. For example, older Indian clients value interdependence and expect to be looked after by their younger counterparts; hence, practitioners must explore interventions that promote independence and autonomy before they integrate them into the therapeutic process. To understand these complex dynamics and individual experiences and values, practitioners must explore these areas of investigation. However, Indian researchers face urgent challenges, such as limited resources, skills, personnel, and budgets, in addition to lack of specialized skills (Shi et al., 2018). Nevertheless, the development of interdisciplinary and interprofessional programs can enable students to work collaboratively with global professionals to promote efficient clinical research.
Practice: Economic, Legal, and Social Considerations
The Ministry of Health & Family Welfare (2019) has proposed universal health coverage across India to ensure better quality, availability, and accessibility of health care and rehabilitation services at lower cost. Although this vision is compelling, especially in the current Indian health care environment, with the prevalence of privatization of health care delivery (Mani, 2011), universal health care will provide optimal benefit only when the shortage of skilled health care workers is met (Ministry of Health & Family Welfare, 2019). Among other health care personnel, allied health professionals are recognized as a pivotal group of independent caregivers who provide services that combine art and science and hence are valued as preventive, diagnostic, therapeutic, and rehabilitative experts (Ministry of Health & Family Welfare, 2019). Also, allied health professionals play a fundamental role in reducing service costs, improving health and wellness, and reducing hospital length of stay. Only a national organization that is affiliated with the central government of India can unite, regulate, expand, and govern this workforce by combining independent allied health associations to gain comprehensive acknowledgement by both the health care system and the overall society (AIOTA, 2016; Ministry of Health & Family Welfare, 2019). To achieve this goal, they have initiated a program to coordinate with allied health professionals by launching a provisional database for voluntary registration. They have also developed key policy documents that include allied health professionals in the Indian health care system. The Ministry of Health & Family Welfare (2019) has recognized and provisionally registered 58 professions, including OT. However, in India, allied health care includes a number of fragmented regulatory bodies that exert jurisdiction at both the central and state levels. In addition, they lack qualified supervisory personnel and have diverse ethical and practice standards (AIOTA, 2016; Ministry of Health & Family Welfare, 2019). Nevertheless, the scope of OT as an effective rehabilitative profession is understood, and the Ministry of Health & Family Welfare (2019) intends to form a liaison with the potential/future national association. Therefore, the AIOTA needs to campaign vigorously not only to demonstrate the visibility and sustainability of OT as an independent allied health profession with unique knowledge, expertise, and capacity to demonstrate sustainability in urban settings but also to emphasize its role in primary (rural) and secondary (semirural/town) settings (Radic & Klepo, 2017).
To practice as occupational therapists in India, at the time of writing, students were required only to complete an undergraduate program accredited by the WFOT or the AIOTA (4.5 years), and registration with the AIOTA was voluntary. However, state regulatory bodies managed the administration, registration, and certification of students and professionals from Maharashtra and Delhi, and graduates from these regions were required to register with these bodies, which had national and international recognition (AIOTA, 2016; Maharashtra University of Health Sciences, 2002). However, other Indian states and territories had no regulatory state associations, thus proving the inconsistency of regulation in India that has prevented the profession from gaining nationwide recognition and status (Mani, 2011).
Because OT is not recognized as an independent allied health profession, practitioners are not included in crucial policy documents, such as the Mental Healthcare Act, 2017 (Gazette of India, 2017) and the Rights of Persons with Disabilities Act, 2016 (Narayan & John, 2017), which delineate their roles by distinguishing and demonstrating their unique contributions to rehabilitation and mental health. Further, the executive summary presented by the Ministry of Health & Family Welfare (2019) and the policy papers presented by the AIOTA (2018) suggest that exclusion of OT from important national bills is a result of the dominance of the medical profession and the power imbalance between physicians and allied health professionals. In India, challenges include overdependence on medicine, lack of awareness of OT, inconsistent educational and professional standards, nonuniform ethical codes, limited culturally relevant practice interventions, and the absence of a centralized body governing OT standards (Ministry of Health & Family Welfare, 2019). In addition, the absence of a central regulatory body leads to insufficient reimbursement packages for OT professionals (Mani & Provident, 2017).
A national organization would enable the development of a formalized system of knowledge that uses occupation-specific terminology, thus building OT expertise and professional identity (Shi et al., 2018). However, this endeavor will require standard ethical guidelines for OT practice. Protocols that are based on Indian culture and presented in a dialect that is understood by both clinicians and the public (Ministry of Health & Family Welfare, 2019; Shi et al., 2018) will lead to the recognition of OT practitioners as autonomous allied health professionals who provide high-quality services.
The limited awareness of OT as an allied health profession in India can be attributed in part to the Indian mindset that depends on medicine to improve health and prevent illness. As a result of this belief, medicine has attained an elevated position not only in the health care system but also in Indian society, leading to the phenomenon of “medicalization,” which has led to a power imbalance between physicians and the rest of the allied health care workforce (Ministry of Health & Family Welfare, 2019). Medicalization is the approach in which human behaviors, problems, and challenges are defined and treated as medical problems; thus, these challenges come under the medical administration. In India, this dynamic results in a hierarchy in which physicians are considered more important than other health care professionals. Additionally, the highly influential self-regulatory body for medicine, the Medical Council of India, has authority over the political, fiscal, and social aspects of Indian health care, which enables this body to exert unequal power over other allied health professionals (Ministry of Health & Family Welfare, 2019). The pansophic image of the medical profession has influenced OT practitioners, as is evident through their emulation of physicians by adopting the medical model of care; a reductionist paradigm of caregiving (where therapists follow an approach that reduces complex and dynamic challenges of health care into a sum of the constituent components [Lim & Duque, 2011]); and even the use of the title of “doctor” (Ministry of Health & Family Welfare, 2019; Rege & Acharya, 2017). This dynamic creates a workforce of Indian OT clinicians who mimic physicians to gain visibility and power. Therefore, a national body must evaluate this power inequality to help allied health professionals to gain status and confidence to function optimally. However, a recent notification by the Ministry of Social Justice and Empowerment (Gazette of India, 2018) included OT as one of the allied health professions that is authorized to issue certification to persons with specific learning disabilities, recognizing the contribution of OT to the field of developmental pediatrics (Gazette of India, 2018).
Another important cause of the limited number of OT professionals is remuneration. Mani and Provident (2017) noted that remuneration of Indian therapists employed in the private sector and located in urban areas ranged from USD 3,700 to USD 5,500 annually. In comparison, in the United States, OT practitioners earn USD 60,000 to USD 80,000 annually. In the United Kingdom, they earn USD 35,000 to USD 54,000 annually (National Career Services, 2017), and in Australia, they earn approximately USD 30,000 to USD 60,000 annually (Australian Government, 2017). These disparities play a crucial role in reducing the workforce in India, and new graduates are often discouraged from seeking employment in India and search for opportunities in other countries (Warhade, 2010).
For OT to flourish in the Indian social climate, culturally relevant practice models and interventions that reflect the nuances of Indian occupations are needed (Lim & Duque, 2011). Rather than directly importing values from the West to solve practice dilemmas, the Indian national association must initiate the creation of local literature in regional dialects (Santos, 2017). For example, in India, a client's therapeutic goals are informed and influenced by family members; therefore, the therapist must understand and delineate personal goals versus family and societal goals. Also, because India has diverse cultures and subcultures, practitioners must understand and acknowledge different food habits, occupations, spiritual practices, clothing variations, and dialects (Shi et al., 2018).
Although practitioners must understand the diversity of clients' cultures and worldviews, all Indian OT practitioners are required to follow certain ethical guidelines delineated by the bylaws of the AIOTA (2013). These ethical procedures are supported by the overarching general code of ethics presented by the WFOT (2016a). However, the Ministry of Health & Family Welfare (2019) reported that ethical guidelines for allied health professionals in India are deficient because they are not uniform. Further, because the AIOTA is a voluntary association, it does not have the authority to exert jurisdiction in the area of ethics (AIOTA, 2016). Hence, there is a dire need for a national regulatory body that can build specific rules of ethical conduct for OT practice in India.
This historical review summarizes the evolution of OT in India, with an emphasis on education, research, and practice, by evaluating challenges and current needs. Evidence supports the need to expand available services, and practitioners are seeking greater visibility for their contributions to Indian society (Srivastava, 2015). However, to increase the efficacy of the profession, OT practitioners must build and promote culturally relevant services that reflect values of justice, peace, equality, cultural relevance, meaning, and advocacy. Practitioners must consider recent social, economic, and political developments that affect health care in India.
India faces a shortage of skilled OT practitioners, lack of a centralized national body, economic challenges, deep influence of the medical model, and inadequate evidence to support clinical interventions (Ministry of Health & Family Welfare, 2019). For a country that has more than 21 million individuals with a disability, the demands for health care are ever increasing and the need for OT practitioners is also continuously rising. Therefore, the expansion of OT in India is dependent on improving current research strategies, creating culturally relevant outcome programs, enhancing educational programs, increasing global networks to create knowledge exchange, and identifying emerging areas of practice.
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