A/HRC/14/20/Add.2 Obstetric and Gynaecological Societies of India, instituted a programme to train general practitioners to provide comprehensive EmOC. In a pilot project, 17 were trained over 16 weeks. The pilot project was run in Rajasthan and Gujarat during 2004–2006. There is now a nationwide scale-up of the programme. 39. The Special Rapporteur warmly commends the Government and the Federation for their bold decision to train general practitioners in comprehensive EmOC – an example of delegation or task-sharing. As the training is scaled up, lessons must be learned from the independent evaluation of the pilot project. As the evaluation observes, “training medical officers in comprehensive EmOC is only one piece of the puzzle”.24 Nonetheless, it is a very important part of the puzzle and it is crucial that all necessary steps are taken to roll out the programme, as a matter of urgency, in Rajasthan, Maharashtra and elsewhere. 40. The independent evaluation found that problems with anaesthesia were the single greatest obstacle for the medical officers who were appropriately trained in comprehensive EmOC. Anaesthetists refusing to work with the trainees at government facilities signal a potentially widespread problem that could hamper the nationwide expansion of the programme. The Special Rapporteur urges anaesthetists, in accordance with their human rights responsibilities, to cooperate fully with this Government-approved programme. 41. Since there are over 20,000 obstetricians in India’s private sector the problem, in relation to providers of EmOC, is not one of national unavailability but of inequitable access. While one way of enhancing access is by delegation or task-sharing, there are others, such as incentives to work in underserved areas, some of which are signalled in later paragraphs. Providers of anaesthesia: delegation or task-sharing25 42. Anaesthesia is an essential component of the provision of comprehensive EmOC. Yet there is a critical shortage of anaesthetists in India’s rural areas, including in Rajasthan and Maharashtra. 43. In 2002, the Government of India developed a 17-week training course, the Life Saving Anesthetics Skills programme, to train medical officers to provide anaesthesia services to EmOC providers. Despite resistance from the Indian Society of Anaesthesiologists, including an unsuccessful legal challenge, the programme has expanded. By 2008, the programme was being implemented in 21 states, including Rajasthan and Maharashtra, with varying degrees of success. By 2009, Rajasthan had trained 33 medical officers under the programme, against a target of 377.26 44. Like the training of medical officers in comprehensive EmOC, training in anaesthesia is “only one piece of the puzzle”. For example, a recent study on Rajasthan reported that in Dungarpur four medical officers had received training in anaesthesia but the shortage of obstetricians, equipment and services, such as blood transfusions, were obstacles to these newly trained personnel.27 45. There is evidence that the Life Saving Anesthetics Skills programme is helping to increase women’s access to lifesaving anaesthesia during obstetric emergencies. Of course, 24 25 26 27 GE.10-12866 Evans and others, “Where there is no obstetrician”, last page. This section draws extensively from D. Mavalankar and others, “Where there is no anaesthetist – increasing capacity for emergency obstetric care in rural India: An evaluation of a pilot program to train general doctors”, International Journal of Gynecology and Obstetrics, vol. 107, No. 3 (December 2009). India, “Rajasthan State report” (Ministry of Health and Family Welfare, 2009), p. 12. India, “2nd Common Review Mission: Rajasthan”, pp. 15 and 16. 11