by Lokesh Krishna1, Surabhi Dharmadhikari1, Siddhesh Zadey2
- RCSM Government Medical College, Kolhapur, MH, IN
- Duke Global Health Institute, Duke University, Durham, NC, US
Correspondence: Siddhesh Zadey BSMS, Candidate for MSc-GH; Address: Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, North Carolina, US 27710; Email: firstname.lastname@example.org; Ph. contact: +1-919-699-9557
Contributions: SZ and SD conceptualized the project. SZ and SD conducted data collection. LK wrote the first draft. All authors reviewed and approved the manuscript for submission.
Acknowledgements: We would like to acknowledge the other members of our research group for support and the authors of the primary studies, particularly Dr. K.D. Rao and Prof. Sudhir Anand for their insights.
Background: Universal healthcare is a basic human right and its provision depends upon the quality of the healthcare systems in place. The healthcare systems in turn are driven by the human resources for health (HRH). India is amongst the 57 nations that have been identified as suffering from a critical HRH shortage. This is a review of the academic literature on HRH in India, covering studies from 1970 to 2018 in order to observe trends, understand the present state, and provide a systematic synthesis of the deficit.
Methods: As per PRISMA guidelines, a PubMed search was conducted in 2018 using the phrase “human resources health India”. Articles were screened to include studies providing data related to cadre-wise HRH enumeration, vacancies, and shortfall. The HRH enumeration data were extracted, reviewed and trends were compared.
Results: Five national-level studies depicted the overall and cadre-wise HRH deficits across two decades. While there has been a 4% increase in the HRH from 2001 to 2012, the density of 14.7/10,000 is short of the WHO recommendations. Unqualified HRH makes up a significant fraction of HRH in India, ranging from 56% to 77% depending upon the year, database, and classification system used. HRH deficit in the rural public sector reveals the problems arising from high vacancy and absenteeism. Medical officers are the cadre with the lowest shortfall at the primary health center level with the health assistant, health worker male, and specialist cadres having high shortfalls. The rural private sector is observed to be a heterogeneous and poorly defined group with a significant number being practitioners without any qualification or an invalid qualification.
Interpretation: The review illustrates the insufficient increase in HRH over the years when compared to WHO’s recommendations. The greatest deficit exists in the cadre of specialists in the rural region. The review reveals that difficulties in maintaining HRH arise from the lack of a central and comprehensive database and shifting definitions. A comprehensive national database covering HRH cadres in public and private sectors could accurately track the state of HRH in India and make necessary policy changes to improve it.
The World Health Organization (WHO) affirms that universal healthcare is a fundamental human right. The maintenance and promotion of good health are assured by efficient and good quality healthcare systems, of which, human resources for health (HRH) form a crucial part. It is the HRH that is ultimately needed to execute policies, perform procedures, dispense medicines, and provide care to the people. It is therefore not surprising that countries with low physician density are seen to perform poorly in life expectancy and mother and child mortality 1,2.
India ranks 154 among 195 countries in the Healthcare Access and Quality Index 3. India is also one of the 57 nations that has been identified as suffering from a critical HRH shortage 4,5. This situation exists despite the recruitment and retention of health workforce being Goal 3.C of India’s Sustainable Development Goals target indicators and HRH being allotted 70% of India’s healthcare budget 6, 7,8.
The HRH for India is divided into the public and private sectors and while the private sectors doesn’t have much of a formal hierarchy of organization, the public health system follows a three tiered model, consisting of a primary, secondary and tertiary level. At the primary level are the primary health centres (PHCs) along with the sub-centres (SCs) and Anganwadi centres. The SCs are staffed with an Auxiliary Nurse Midwife (ANM) and a Male Multipurpose Worker (MPW) also known as the Health Worker Female and Male (HWF/HWM) respectively. The MPW/HWM is the grass root level health functionary for communicable disease control, sanitation and health education. Anganwadi centres are non-formal pre-schools that serve as centres for rural child and reproductive health and are staffed with Anganwadi workers. Another health worker who is a part of the primary level is the Accredited Social Health Activist (ASHA), a community health volunteer that operates part-time at the village level and acts as a link between the people and the public health system. The secondary level is made up of community health centres (CHCs) and sub-district hospitals (SDHs). The tertiary level is the highest level of care offered in the public health system and consists of medical colleges and district hospitals (DHs). Doctors are an essential part of the public health system and doctors of varying levels of specialisation are present at all the levels of the system. They can belong to the allopathic system of medicine (MBBS) or one of the many native or alternative systems of medicine such as Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy that are together called AYUSH. The nursing staff can be ANMs, General Nurse Midwives (GNMs) or have a Bachelor of Science (BSc) degree in nursing. Apart from doctors and nurses, the public health system is made up of lab technicians, radiology technicians and pharmacists whose staffing varies depending upon the level of the health care center.9 The private sector is loosely organized into qualified and unqualified health care providers with the qualified segment consisting of professionals with a qualification recognized by the government while the unqualified segment consists of people with no formal training, having trained as apprentices under qualified professionals or with qualifications that are not recognized by the government. 10
Understanding the structure of shortage in a country with abundant human resources is crucial from the policy viewpoint. Although India faces glaring issues in public health, research attention towards the issue has been limited 1. Here, we present a review of the academic literature on HRH in India from 1970 to 2018 and provide the present situation along with trends and the nature of the shortage.
2.1 Data Sources and Synthesis
Articles were extracted from a Pubmed search conducted using the phrase “human resources health India” in September 2018. Articles were screened at title, abstract and full-text levels for relevance for inclusion by two independent investigators as per PRISMA review guidelines 11. References of the included articles were also screened in a snowball mechanism, i.e, hand searching of citations in the full texts. Studies focusing on the quantification of HRH (absolute numbers/shortage/vacancy/shortfall) at national/sub-national levels in urban/rural areas in the Indian context were included. Studies with estimates on dentists or students alone, review articles with no original analysis, articles that were not in English, commentaries, perspectives, and articles with full text unavailable were excluded. 1492 titles were discovered in the initial screen, of which 1212 were excluded after reviewing abstracts. 280 full-text articles were assessed for eligibility of which 22 articles are included here (Figure 1).
2.2 Data Analysis
We scrutinized the studies for data related to HRH enumeration, vacancies, and shortfall. The available data was modified for uniformity and comparison with WHO standards as required. For e.g., all the HRH densities are recalculated and reported as HRH personnel/10,000 population. We calculated the doctor, nurse, and midwife densities from the extracted data when not readily available. Similarly, all vacancies and shortfalls have been reported as percentages to ensure uniformity. This is a qualitative synthesis/summary. No meta-analytic estimates were modeled based on the values from the studies.
3.1 The national-level pictures of India’s HRH
The scoping review identified five national level cross-sectional studies analyzing the HRH data in India. Figure 2 compiles the HRH densities and Table 1 summarizes the main findings of these studies. Since WHO takes into consideration the doctor, nurse, and midwife cadres as essential HRH, comparable numbers have been calculated from the available data. Estimates from the Census, the National Sample Survey Organisation (NSSO), professional registration councils, and the Center for Monitoring Indian Economy (CMIE) were seen to be the primary data sources for the studies. The earliest analysis of HRH relies on data from CMIE, a private organization 12. It is, however, limited to 15 states, covering 93% of the population at the time of the study. Anand, S. & Fan, V. (2016)13 provide an exhaustive analysis of the Census data obtained at the district level from the Registrar General of India. Rao, K. D. et al. (2012) and Rao, K. D. et al. (2016) (Table 1) seem to have access to limited census data. The census data contains self-reported occupations and cannot account for unqualified providers, potentially leading to bias or overestimation 14,15. Studies have tried to rectify this by conducting validation/correction procedures using NSSO data. Registration council data, used by Hazarika et al (2013)16 has the advantage of counting qualified workers only but does not account for professional inactivity, retirement, or migration of HRH 15.
Across-study comparisons are limited by the different sources and recording periods of the data. However, an estimated 4% (20.1/10,000 to 20.9/10,000) increase is seen in the total reported HRH from 2001 to 2012 with a reversal in the Nurse:Doctor ratio from 0.8 to 1.1 (Figure 1, Table 1)13,15. In spite of the increase, the 2012 HRH (doctors, nurses, and midwives) density is only 33% (14.7/10,000) of the density recommended by WHO (44.5/10,000) 17. WHO benchmarks do not take into consideration other paramedical (technicians, pharmacists) workers and traditional and faith healers. Upon including them, the reported 2012 density rises to 20.9/10,000. Further, the National Classification of Occupations (NCO) that has been used to categorize HRH by the above studies does not include a separate category for community health workers (CHWs) like Accredited Social Health Activists (ASHAs), Anganwadi workers, Village Health Guides (VHGs), and Health Workers Male (HWM) posted at Sub Centers (SCs), since these health workers are considered part-time. Except for the inclusion of health workers by Purohit et al (2004)9, it is unclear if such health worker cadres are included in the enumeration resulting in the underestimation of existing HRH.
The studies depict a glaring problem of unqualified HRH which form 56% (11.8 of 20.9/10,000)15 (2012) to 77% (15.4 of 20.1/10,000)13 (2001) of the total HRH. Counting only the qualified HRH lowers the 2012 density for doctors, nurses, and midwives to about 15.7% (7.0/10,000) of the WHO recommendation while the HRH density for the total of all cadres falls to 9.1/10,00015. Upon considering the increase in qualified workers only, from 2001 to 2012, an incredulous 93.6% (4.7/10,000 to 9.1/10,000) increase is seen in the total reported HRH with a corresponding increase in the Nurse:Doctor ratio from 0.2 to 0.8 (Figure 1, Table 1)13,15. The contribution of practitioners of Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) and traditional healers to the total HRH is seen to be less in number as compared to other cadres.
The national HRH is not evenly distributed and shows a preference for states with higher GDP, more urban areas, and the private sector. Further, rural areas have a higher proportion of unqualified providers than urban areas (Tables 1). Studies enumerating the HRH in the rural public and private sector have been presented in the following sections. However, no studies exclusively reporting on urban HRH enumeration, private or public, were found in this review.
3.2 Rural picture of the HRH
Rural India is served by a well-defined public and a heterogeneous private HRH. HRH in the rural public sector is placed at Sub-Centers (SCs), Primary Health Centers (PHCs), and Community Health Centers (CHCs) that are supposed to comply with the Indian Public Health Standards (IPHS) guidelines (2007, revised in 201218). The deficit in meeting the IPHS norms is recorded as the ‘shortfall’ while that in filling the sanctioned posts is reported as ‘vacancy’. Hence, the vacancy might be different from the shortfall.
3.2.1 Rural Public Sector
188.8.131.52 HRH deficit across cadres
Studies on the HRH working in the rural public sector are enumerated in Table 2A&B19,20,21,22,23,24,22. The following results are brought forth in Table 2A&B.
Nationally, specialists at the CHCs are the most deficient cadre as measured by vacancy and shortfall. No study included here notes the nationwide vacancy/shortfall of Medical Officers (MOs), Allopathic or AYUSH at CHCs. At the PHC-level, MOs are seen to have the least vacancy and shortfall amongst the included cadres. In nationwide studies, the numbers for nurses and midwives are not reported separately for PHCs and CHCs, making center-level inferences difficult. However, the combined (PHC and CHC) nationwide vacancy and shortfall for these cadres seem to be more or less at par with PHC-level MOs. An experienced Health Worker Male (HWM) or Auxiliary Nurse Midwife (ANM) placed at the PHCs is called a Health Assistant (HA). A high shortfall of HAs is seen at PHCs. At least one HWM/ANM is positioned at 99.6% of SCs. The vacancy/shortfall of ANMs is consistently lower than that of HWMs. The above-mentioned differences could arise from funding being sourced from the central government for the former and the state government for the latter25. On the whole, the shortage is much higher amongst the specialists, HAs and HWMs compared to other cadres such as MOs, nurses, and midwives, with specialists being the cadre with the greatest shortage.
184.108.40.206 HRH absenteeism
It is credulous to believe that the vacancy/shortfall figures are an adequate depiction of the HRH availability at public health centers. A public facility survey of 143 facilities serving randomly selected villages in Udaipur district, Rajasthan revealed absenteeism of HRH staff of up to 45% at SCs and 36% at PHCs and CHCs which was verified through weekly visits 26. However, this survey only included villages where the affiliated NGO was active leading to potential bias. Another study of five randomly selected PHCs out of thirty-one in Bangalore district revealed that the functionality of the HRH ranged from 25% to 81% 27. The calculation metric for the functionality is not clearly defined in the study. When the doctors and nurses are absent, it is the less qualified (e.g, nurse in the absence of doctors) or unqualified (e.g, clerical staff) HRH that provides healthcare services at the public centers 28. This is reaffirmed by a study of randomly selected providers in rural Madhya Pradesh using standardized (mock) patients where 63% of patient interactions were seen to be with HRH other than doctors, that were not qualified for such interactions 28.
3.2.2 Rural Private Sector
Although a majority of the HRH are employed in the private sector, organized data on the private sector is unavailable 14,28. The practicing HRH cadres are referred to by different names which we have blanketed under the term ‘practitioner’. The relative numbers of qualified and unqualified practitioners can be extracted from eight studies (Table 3A&B).
220.127.116.11 Qualified Private Practitioners
A nationwide cross-sectional study of 812 rural private practitioners shows that qualified private practitioners make up from 39.7% of private practitioners in the North to 57.1% of private practitioners in the West (Table 3). Their proportion in locally conducted cross-sectional studies shows an even wider range (Table 3A&B), showing the significance of unqualified private practitioners as a major fraction of health providers in rural regions. Barring the southern region, these private practitioners are mainly AYUSH trained doctors (Table 3A&B). Moreover, the majority of them prescribe pharmaceutical drugs instead of medications from their own medical system28.
18.104.22.168 Practitioners with invalid or no qualifications
Practitioners without any qualification or those with an invalid qualification are also a significant proportion of healthcare providers in rural areas. Such practitioners have been around for decades and are a heterogeneous cadre 29,30. They are primarily people who have an unrecognized degree or were apprentices to qualified or unqualified practitioners and practice allopathy 10,31–33. Some of them identify as Registered Medical Practitioners (RMPs), derived from an old provision that registered unqualified practitioners decades ago14. They provide services ranging from treating common ailments, performing minor surgeries to managing emergencies (Table 3). Unmanageable cases are referred by them to qualified practitioners for which they may or may not receive incentives 10. They are often integrated into society through well-formed RMP organizations and support from politicians 34. They may or may not enjoy good relations with qualified practitioners 10,34.
We have sought to provide a scoping comparative review of studies across years on the shortage of human resources for health in India and the distribution of said shortage, across cadres. In our review, we found a lack of availability of literature enumerating public and private HRH in urban areas.
The studies reporting national HRH densities were heterogeneous for data sources, e.g. sample surveys vs. census vs. registries, making longitudinal comparisons difficult. These databases come with differing advantages. For instance, the census is more comprehensive than others but is limited by a lack of verification of responder claims. Others, such as the NSSO surveys have verified data with greater scrutiny but small samples. Our comparisons should be perceived with the above consideration in mind.
The need for collection from disparate datasets highlights the lack of a comprehensive standardized HRH database with verified qualification status for personnel along with the location (rural, urban, etc.) and sector (public, private, etc.) of practice. Such a database could leverage the National Health Workforce Accounts system developed by WHO and its partners which would not only increase compatibility of data nationally but also globally35. Nations like Canada have a comprehensive database that provides information at the national, provincial and territorial level in different domains that can be used as a role model to build upon36. The lack of a database is especially true for the urban and private sector. A good example of this is a perceived 93% increase in qualified HRH between 2001 and 2012 with a corresponding increase in total HRH over the same period of 4%. This is likely due to the use of different data sources and their differing definitions for qualified HRH. While recent developments have made HRH data available for the public sector under the National Health Mission (NHM)37, data on private practitioners in rural and urban areas are still missing. This is a pressing issue in a nation where the majority of medical practitioners are not a part of the NHM. While each state’s respective medical council maintains a register of its members, these might miss cases of death, retirement, or migration within or out of the country. A register that takes into account private practitioners is maintained at the national level and is periodically updated would overcome these shortcomings.
Attempting to get an idea of the state of HRH in India is complicated by the interchangeable use of the terms vacancy and shortfall, thereby skewing decision-making and public perception. For instance, a high vacancy could be the result of the over-sanctioning of posts and may not reflect a true shortfall. Absenteeism also undermines the inferences solely based on HRH availability. It is possible to have healthcare workers on paper who are not actually present. Further, absenteeism can range from never being present at the post to frequent leaves and evasion of duty26,27,28. Understanding its prevalence in the public health sector would require studies focused on measuring it based on clear categorizations.
WHO’s current methods for calculating HRH density requirement thresholds take into consideration three cadres of healthcare workers: doctors, nurses, and midwives, thereby discounting other paramedical workers that form an unignorable section of the HRH of India. Variants of such paramedical workers are also present in other LMICs, are known by different names, and serve diverse functions38. Especially in the rural setting, these paramedical workers play a significant role in health care delivery. Excluding them from calculations of essential HRH density delegitimizes their role and fails to provide a complete picture of the HRH availability and distribution.
Efficient and equitable policies rely on accurate knowledge of the state of affairs at adequate resolution. Decisions taken in ignorance or indifference of it will grow increasingly disconnected from the ground reality. For instance, the review notes that the real shortfall lies in the specialist cadre and is more marked in rural areas when compared to MOs and this is something that could inform policy decisions. Absenteeism of cadres is also a problem and policies that simply focus on sanctioning more people to reduce vacancies will not necessarily help in improving attendance or retention. Unqualified HRH is a major segment of the health providing workforce in the rural private sector and it might be beneficial to integrate them in the mainstream via adequate training25. Our review strongly points towards the benefits of future policies accounting for the above-mentioned issues.
This study has several limitations. The search used for our review needs updating and this is being done in a prospectively-registered larger scoping review on the same topic that we are conducting currently. While the search is both generic and comprehensive, it is limited to only PubMed and no other databases have been included. However, we conducted an extensive snowballing of the references of the included studies to identify additional relevant citations. As this review was a pilot, it was not pre-registered but PRISMA guidelines were followed.
The review shows that there has been a consistent deficit in HRH in India over the years (1971-2014)19,27, with the greatest deficit seen in the rural specialist cadres. A comprehensive centralized HRH database that includes high-resolution data with demographic (urban vs. rural), sector (public vs. private) and cadre (surgeons, nurses, community health workers, etc.) partitions are needed to implement accurate monitoring of the HRH in India.
2. Dhillon, P. K. et al. Status of epidemiology in the WHO South-East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity. Int. J. Epidemiol. 41, 847–860 (2012).
3. GBD 2015 Healthcare Access and Quality Collaborators. Electronic address: email@example.com & GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet 390, 231–266 (2017).
15. Rao, K. D., Shahrawat, R. & Bhatnagar, A. Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey. WHO South East Asia J Public Health 5, 133–140 (2016).
19. Sodani, P. R. & Sharma, K. Assessing Indian public health standards for community health centers: a case study with special reference to essential newborn care services. Indian J. Public Health 55, 260–266 (2011).
21. Reddy, N. B., Prabhu, G. R. & Sai, T. S. R. Study on the availability of physical infrastructure and manpower facilities in sub-centers of Chittoor district of Andhra Pradesh. Indian J. Public Health 56, 290–292 (2012).
22. Bashar, M. A. & Goel, S. Are our subcenters equipped enough to provide primary health care to the community: A study to explore the gaps in workforce and infrastructure in the subcenters from North India. J Family Med Prim Care 6, 208–210 (2017).
30. Neumann, A. K., Bhatia, J. C., Andrews, S. & Murphy, A. K. S. Role of the indigenous medicine practitioner in two areas of India—Report of a study. Social Science & Medicine (1967) vol. 5 137–149 (1971).
38. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. CHW Central https://chwcentral.org/resources/community-health-workers-what-do-we-know-about-them-the-state-of-the-evidence-on-programmes-activities-costs-and-impact-on-health-outcomes-of-using-community-health-workers/ (2013).
7 Figure Captions