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Chapter # 29. Human Resources for Health

Objectives 

  • Achieve a doctor-population ratio of at least 1:1400 (WHO norm 1:1000) and nurse-population ratio of at least 1:500 (WHO norm 1:400) by 2022-23.
  • Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norms in high priority districts by 2020 (National Health Policy, 2017).
  • Deploy mid-level providers (MLPs) to manage the primary healthcare system.
  • Generate at least 1.5 million jobs in the public health sector by 2022-23, a large number of which will employ women.

Current Situation 

India’s health workforce is characterised by a diversity of providers delivering services in allopathy and alternative systems of medicine like ayurveda, homeopathy, unani and siddha.

As of March 2017, there were 10.23 lakh allopathic doctors registered with the Medical Council of India or state medical councils. Assuming 80 per cent availability, it is estimated that around 8.18 lakh doctors may actually be available for active service. This gives a doctor-population ratio of 1:1613.

The current nurse-population ratio is 1:588.1 Due to the suboptimal quality of training offered by several institutions that have mushroomed over the years, limited career prospects and poor working conditions, especially in the private sector, there is a significant shortage of skilled nurses in the country.

Moreover, the distribution of doctors and nurses across the country is uneven. Urban areas have four times as many doctors and three times as many nurses as compared to rural areas. Medical and nursing colleges are concentrated in a few states, e.g., Andhra Pradesh, Karnataka, Tamil Nadu, Kerala, Gujarat and Maharashtra.

There are also severe shortages in the category of allied health professionals (AHPs) including medical lab technicians, optometrists and radiologists. For instance, as of March 31, 2016, there was a shortfall2 of 13,659 lab technicians at primary health centres (PHCs) and community health centres (CHCs) across India.

Similarly, there was a shortfall of 3645 radiographers at CHCs. The absence of a central regulatory authority for AHPs has resulted in the mushrooming of institutes/ colleges without affiliation or recognition, giving rise to quality issues for this category of health professionals as well.

As far as specialists are concerned, a large number of posts are vacant all over the country. According to estimates, India needs close to 0.5 million additional specialists. Ayushman Bharat has triggered the need for even more human resources for health (HRH).

There is also an acute shortage of medical faculty. Of the 1,830 faculty posts across six All India Institutes of Medical Sciences (AIIMS), approximately 583 (31 per cent) had been filled up until July 2017.

The government has made several efforts to address the shortage and quality of HRH in the country. These include the passage of the National Medical Commission (NMC) Bill, 2017 by the Union Cabinet, addition of 15,364 undergraduate and 9,855 postgraduate seats in medical colleges as well as increasing the superannuation age of doctors to 65 years in the Central Health Service, among other measures. Steps have also been taken to address the shortage of specialists through the system of diplomas from the College of Physicians and Surgeons (CPS), for instance.

Constraints

  • The regulatory system (Medical Council of India, Nursing Council of India) has failed to ensure adequate availability and quality of health professionals.
  • There is inadequate capacity to train doctors, especially specialists and super-specialists.
  • Private practice by medial faculty in teaching institutions is rampant in several states, compromising on the commitment to teaching and institutional clinical work.
  • Many state and private medical/nursing/dental colleges have poor infrastructure.
  • There is no comprehensive and consistent HRH policy.
  • Workforce shortages and uneven distribution of doctors, nurses, specialists and allied health professionals plague the sector.
  • The quality of health professional training and adherence to standards is sub-optimal, including in the private sector.
  • Health professionals in the public sector are inadequately compensated and motivation levels are extremely poor. Fair compensation in the private sector, e.g., for nurses, is also a challenge.
  • There is paucity of data on HRH in the country.

Way Forward

  1. Reform the governance of medical, nursing, dentistry and pharmacy education in the country
  • Enact the NMC Bill, 2017.
  • Revamp the AYUSH, nursing, dentistry and pharmacy councils along the lines of the NMC Bill, 2017.
  • Establish a Council for Allied Health Professionals to ensure standardization of education and putting in place quality control mechanisms for educational institutions, teaching methods, clinical protocols and workforce management.
  • Put in place an updated curriculum for medical and allied professions that keeps pace with the changing dynamics of public health, policy and demographics.
  • Establish a nursing school in every large district or cluster of districts with a population of 20-30 lakhs as per the National Health Policy, 2017.
  • Take steps to revamp the regulatory system of nursing education, ensure quality training in nursing schools, develop specialties in nursing, develop centres of excellence in nursing and enhance the stature of government nurses.
  • Take steps to stop private practice by faculty of government teaching institutions by providing attractive salaries and incentives.
  1. Enhance production of doctors (especially specialists and super- specialists)
  • While some steps have been taken, the system of Diplomate of National Board (DNB) and Diplomas from CPS, may be expanded. This will help to address the shortage of specialists in the country.
  • Link at least 40 per cent of district hospitals with medical colleges.3
  • Meet faculty shortages in new AIIMS with an active search strategy, visiting/adjunct faculty system (from India and abroad), and other methods.
  • Create pathways for training of doctors in specialties and super-specialties at private hospitals (certification, short courses, exchange programmes, etc.)
  • Utilize extensively and incentivize district hospitals for formal (DNB/CPS diploma) and informal specialty training of doctors and nurses.
  • Provide opportunities for training in specialized/cutting edge areas at the best centres in the world for faculty of national institutions of excellence (NIEs) (AIIMS, PGIMER, JIPMER, NIMHANS) and of state medical colleges of repute.
  • Create conditions to facilitate the import of doctors, especially those of Indian origin, working abroad.
  • Consider deploying teachers from universities abroad as visiting professors at AIIMS/NIEs.
  • An enabling framework for deployment of doctors and specialists from the private sector to government hospitals on a visiting/honorary basis may be developed and piloted.
  1. Develop a comprehensive HRH policy in states 
  • To enable the formulation of a comprehensive HRH policy in states for all categories, develop a model policy covering issues pertaining  to staff recruitment, retention, transfer, incentive structures for posting in difficult areas including access to housing facilities, performance management and competency-based career tracks for professional advancement.
  1. Skill and deploy non-physicians and other health providers
  • Develop plans for training a full range of allied health professionals such that it meets national requirements as well as creates a surplus for placements abroad.
  • Create a cadre of primary healthcare practitioners by introducing a three-year competency-based dynamic course for primary, community and family medicine.
  • Place 150,000 skilled and independently certified MLPs to manage the health and wellness centres to be operationalized over the next five years.
  • Explore some specific task shifting opportunities like developing a cadre of nursing practitioners and physician assistants.
  1. Generate data on HRH, track progress
  • Generate comprehensive real-time data on forecasting, production capacity and skill mix as well as generate trends with respect to the key categories of HRH in the country.
  • By 2019, put in place a system for tracking progress against the stipulated HRH requirements.
  • Ensure meeting country commitments and targets under the Global Strategy on HRH.4
  1. Engage private sector for skilling and training HRH
  • Establish partnerships with medical device manufacturers as part of the Skill India and Make in India programmes to identify skill gaps and design appropriate curricula for training programmes.
  • Partner with private hospitals/private medical practitioners to skill technicians, nursing and para-nursing as well as para-medical staff under the National Skill Development Corporation’s Healthcare Sector Skill Council.

NITI AYOG - New India @ 75

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