Human resources for health (HRH) are one of the six building blocks of health systems and are central to their effective functioning. Any form of planning for future policy action can be undertaken based on the assessment of the current status. Capacity and capability planning is significantly hampered by the lack of robust data on the entire range of human resources actively engaged in meeting the health needs of the people. The Central Bureau for Health Intelligence (CBHI) under the Union Ministry of Health and Family Welfare published data on HRH as part of its yearly National Health Profile (NHP-2019) report. It acknowledges the limitations in gathering accurate information on HRH in the country.
Supply side information
As of 2018, there were 11,54,686 registered allopathic doctors, 799,879 registered AYUSH doctors, 2,54,283 registered dental surgeons, and 11,25,222 registered pharmacists in India as per the respective councils’ registers. There were a total of 8,60,927 serving ANMs and 20,48,979 registered nurses and midwives as of 2017. There were 529 medical, 313 BDS dental, 253 MDS dental, 1,909 ANM, 6,861 nursing, and 1,682 pharmacy colleges as of end 2017. There were 58,756 admissions in medical, 26,960 in BDS, 6,288 in MDS, 55,263 in ANM, 2,67,564 in nursing, and 99,145 in pharmacy colleges for academic year 2018-19. There are 1,16,757 allopathic doctors, and 7,337 dental surgeons in government facilities. State-wise details are provided in the report.
While there is accurate information on registered professionals and new admissions to various health professional colleges, there is no information on the number of professionals in active healthcare services and their geographic distribution. The National Digital Health Blueprint (NDHB) has outlined a plan to create national registers for various providers as a single source of information. This is aligned with the National Health Resource Repository (NHRR)’s vision of creating a robust, standardized, and secured information technology enabled repository of country’s healthcare resources.
Demand-Supply gap assessment
The demand for doctors is defined by the healthcare needs of the people, which in turn depends upon the demographics and the disease burden. In addition, the health seeking behavior of people also influences demand. The time and distance to access a doctor (allopathic or AYUSH doctor or a dental surgeon), especially in times of emergencies, is a surrogate indicator of the demand-supply gap. The percentage of people seeking care from informal providers is an indirect reflection of the gap in the availability of formal health professionals. Population surveys attempt at qualitative assessment of this gap through various questionnaires.
The adequacy of Auxiliary Nurse Midwives can be better assessed by the number of women requiring maternal care. Assuming a birth rate of 2 percent per annum, the number of women needing ANMs’ care works out to ~270 lakhs per annum. Since there are ~9 lakh ANMs in India, each ANM has to take care of 30 pregnant women and 30 new born children per year. The ratio looks reasonable and adequate.
A majority of nursing staff are engaged in taking care of hospitalized patients, as their need in clinics is limited. Usually non-nursing personnel (formal or informal) assist doctors in outpatient clinics. The decision to deploy trained nursing personnel such as the mid-level health worker or the community health officer in the 150,000 planned health & wellness clinics under Ayushman Bharat will increase the supply of nursing staff in primary care.
Public healthcare facilities (sub-center, Primary Health Center, Community Health Center, Area hospital, District hospital, and referral teaching hospital) have sanctioned posts for healthcare professional as per the Indian Public Health (IPH) standards. Sanctioned versus actual serving staff positions indicate the extent of supply side gap. Staffing position in private healthcare facilities is largely unknown. The limitation of conducting a supply-side gap assessment is that the demand may vary significantly from one facility to the other.
Attrition of health professionals
While there is information on the number of health professionals coming out of educational facilities, information on their attrition over time is not robust. A good proportion of professionals migrate to other countries in search of better prospects. A percentage of qualified health professionals choose other sectors that includes management, pharma industry, biomedical and biotechnology industries, and consulting firms among others. A sizeable number of female health professionals discontinue their professional engagements to take care of their families. Many health professionals continue their professional career beyond the age of retirement. Hence, for good planning it is important to have a system that updates the information on number of health professionals in active service.
Adaptive behavior of health systems
The growth of informal healthcare providers in rural India reflects the inadequacy of the supply of formal health professionals. Strategies like compulsory posting of postgraduate students in villages has not yielded the desired result as it takes time for people to place trust and confidence in health professionals. The proposed cadre of mid-level health workers for the Health and Wellness Clinics may bridge a part of the need. However, it may not replace the need for qualified medical professionals in these centers. The Covid-19 pandemic has pushed patients to adapt teleconsultations. While telemedicine improves access to not only primary care physicians but also to various specialists, it may not be the right substitute for in-person interaction in the long term.
Despite the stated shortage of health professionals, the waiting time to get an appointment with a doctor in India is probably the shortest. Throughput of an average physician in India is far higher than that in developed countries due to multiple factors. Documentation requirements are far lower and relaxed in India. The medicolegal environment is not as evolved as in the west. Evening clinics have evolved in response to the needs of the working people. Some of these clinics run even up to midnight or beyond!
Accredited Social Health Activists (ASHA) have emerged over the last few years as a critical link between communities and health systems. Numbering nearly one million, they have become a vital part of health and social systems. While the initial focus of ASHAs was on mother & child health, their services are being increasingly utilized in various prevention programs for communicable and non-communicable diseases. Auxiliary Nurse Midwives (ANMs), numbering nearly 0.9 million, continue to play an important role in the care of pregnant women and in vaccination programs.
Policies addressing human resources for health
The privatization of health professional education was the first major policy that addressed the shortage of HRH in India. The impact is clearly reflected in the number of new colleges and yearly admissions seen over the years. The first All India Institute of Medical Sciences was established in Delhi in 1956. Since then, 22 more AIIMS have been announced, of which 15 have become operational as of 2020 and seven more are expected to become operational by 2025. The Employee State Insurance Corporation has fourteen medical and dental colleges. The NITI Aayog has recommended the conversion of district hospitals into teaching hospitals for medical colleges to address HRH shortage and to strengthen specialty referral services in districts. The states of Telangana and Andhra Pradesh have announced many new medical colleges as part of their health systems strengthening initiatives.
The National Medical Council (NMC) has replaced the erstwhile Medical Council of India (MCI) through an act of parliament, to improve medical education in the country. Common nation-level entrance and exit examinations (NEET and NEXT) are being held to improve transparency, objectivity, and quality of medical professionals passing out of various colleges across the country. Steps are being taken to focus more on competency-based education and training. Standards are being revised to make them more practical and pragmatic. Various decisions are being taken to address the shortage of quality teachers. The National Board of Examinations (NBE) that oversees postgraduate and doctoral training is being strengthened to address the acute shortage of specialists in view of the rising incidence of non-communicable diseases in every state of India.
The process for licensing foreign medical graduates is fairly stabilized now. Many Indian nationals are studying in various medical colleges located in other countries, including those in the middle-east, Philippines, China, Russia, Caribbean islands, Mauritius etc. The need for Indians to go overseas for undergraduate medical education may come down with the ongoing policy reforms aimed at increasing the educational capacity both in public and private sectors.
There have been policy discussions around licensing trained nurses as nurse practitioners with the right to prescribe limited drugs and diagnostics, especially in the area of preventive and primary care areas. Designating trained nurses as mid-level healthcare providers in health & wellness centers appears to be a step towards licensing nurse practitioners.
The Parliament has recently passed the bill on Allied Health Professionals (AHP), paving the way for standardizing the growing importance of these professionals in catering to the varied health needs of the people. While doctors and nurses remain the mainstay of HRH, these allied professionals enable task shifting and task sharing of non-core functions of doctors and nurses. A well-trained physician assistant will increase the productivity of a doctor by almost 50 percent while improving the patient experience with the team. A podiatrist has become as important as a diabetes specialist in preventing foot ulcers and gangrene. Physiotherapists have become an integral part of rehabilitation and chronic pain management. Behavioral therapists are supporting weight loss and deaddiction programs, improving drug compliance, and addressing common mental illnesses.
Global labor market for health professionals
With an ageing population and prevalence of life-long diseases, the demand for trained health professionals is increasing across the world. The developed world attracts a larger share of health professionals, thereby depriving the developing and underdeveloped countries of their precious HRH. However, it also offers a unique opportunity for countries to capitalize on the growing international health professional labor market, provided they don’t compromise on their own needs. Foreign remittances accounted for 2.6 percent of India’s GDP in 2017. Health professionals’ migration is a fact and should be accounted for in any planning.
Future role of Artificial Intelligence (AI) and Machine Learning (ML)
We are already witnessing the impact of disruptive digital technologies across health sector. By enabling self-care and robot-assisted care, these technologies are dramatically expanding the cadre of care givers. AI enabled diagnostic and clinical decision support skills are matching those of experienced clinicians, radiologists, and pathologists. Telemedicine is dramatically bridging the geographic divide thereby addressing the issue of unequal distribution. Hence, planning for HRH should incorporate the likely impact of these technological disruptions.
Recommendations on HRH planning
Decentralized (district or sub-district) planning to help meet the local health needs of people is preferred over the age-old method of using the macro-level indicator of number of health professionals per 10,000 population. The time taken to access a trusted doctor, nurse, allied health professional in emergency and elective situations is a better indicator of the demand-supply gap. Task shifting/ sharing to trained allied health professionals or even AI systems will increase the productivity of existing resources. Reforms in health professional education standards should aim at increasing the output of these professionals with focus on building their competencies to meet the growing local and global needs. A standardized national register of all health professionals that is periodically updated to provide information on actively working health professionals is essential for good planning.
Dr Krishna Reddy Nallamalla
President, InOrder
Country Director, ACCESS Health International
Photo Credit: India Legal