CHAPTER X

ESTIKATES Q£ llllRSIBG. KABPOUR. REQUIREMENTS u.em. 2tllU ..

In this section, an attempt is made to work out the

" requirements of nursing manpower upto 2001 using alternative

methods. The exercise is however confined to two categories

of nursing personnel viz., general nurses and'auxiliary

nurse midwife. The methodology for estimating the demand

for these two categories is not the same, therefore, the

discussion has been made separately for each one of them .

. Attempt has been made to work out the requirements for each

state separately.

- General Nurses

As mentioned earlier, the requirements of general

nurses have been worked out using following ~lternative

methods": -

Method I

Method II

Method III

Method IV

- Nurse: population ratio norms,

- Nurse: doctor ratio norms,

- Relationship between the growth

stock of nurses and increase

health expenditure and

- Component/Programmatic approach

259

of

in

state-wise requirements of nurses have been worked by

using methods I and IV only. Methodological.details giving

the various steps involved and the assumptions made in the

process are described in the succeeding paragraphs.

Method ~ ~ Nurse ~ Population Ratio

In their report published in 1946, the Shore Committee

had considered nurse population ratio in some well developed

countries and had suggested a norm of one nurse per' 500

population to be achieved by 1976. On the other hand,

Mudaliar Committee had recommended a ratio of 5000, 2000 and

100D persons per nurse to be achieved by 1971, 1981 and 1991

respectively.

It may be mentioned here that the ratios recommended by

the various Committees referred to above were more of im-

pressionistic nature based on the ratios prevalent in

countries. In the present exercise we have determined

other

the

nurse population ratio considering the various constraints

reflected by the trends of past performance at the national

level and for' each state separately by fixing appropriate

targets of nurse population ratio. The. nurse population

ratio which was 8241 in 1971 has steadily improved to 6308

in 1981 and further to 4967 in 1991. This has been assumed

to be '.3638' for the year 2001, which is still far less than

what was recommended by Bhore and Mudaliar Committees. The

state-wise estimates of requirements for the year 2001 are

presented in the Table 10. 2 along with the nurse

260

population- ratio in the years 1971. 1981 and 1991 and the

ta~geted ~atio fo~ 2001.

The Table 10.1 below p~ovides the actual data on popu-,

lation pe~ nu~se for the period 1971-1991 at quinquennial

inte~vals.

Year

(1)

1971

1976

1981

1986

1991

Table 10.1

Population per Nurse (Total 8ct-abour Fgrce) durinq the period 1971-91 - at quinquennial intervals

Total Population in OOO's

Estimated StocK of nurses

Population per nurse

Source

Total LF Total LF

(2 ) (3 ) (4) (5) (0 )

548,160 72,303 66,519 7581 8241

612,575 93,504 86,024 6551 7121

683,329 117,749 108,330 5803 6308

761,102 148,751 136,851 5117 5562

844,324 184,779 169,997 4569 4967

(i) Census of India - 1991, Se~ies I, P~ovisional

Pape~ No.2, 1991, New Delhi, pp.15-19.

(ii) Census Se~ies

1975.

of India, General Population I - INDIA pi II A (i), New

261

Tables, Delhi,

Table No. 10.2

statewise Requirements of Nyrses on thg basis of Population : Nurse norm for the year 2Q01

States Population Targetted per Nurse in population

------------------------nurse ratio 1971 1981 1991 in 2001

1.

3.

4.

5.

6.

8.

9.

( 1 )

Andhra Pradesh

Assam

Bihar

Gujarat

Haryana

Himachal Pradesh

Jammu & Kashmir

Karnataka

Kerala

(2 )

8285

16220

22221

7981

13527

7425

11689

7394

10. Madhya 9211 Pradesh

11. Maharashtra 43q4

12. Orissa 13630

13. Punjab 11783

14. Rajasthan 9438

15. Tamil Nadu 6379

16. Uttar 22320 Pradesh

17. West 5374 Bengal

18. Other States 2262 and Union Territories

19. All India 8241

(3)

7459

8072

11982

5518

9250

4881

8870

5975

5519

6649

3370

9391

6497

6616

4694

15582

50$3

1987

6308

•

(4 )

6313

61B8

8234

3902 \

7407

3968

8083

4790

2509

5862

3069

6842

4488

4'Scrq

3499

11319

4475

1988

4967

262

(5 )

4624

4532

5658

2759

5425

2906

5920

3508

1838

4294

2248

4985

3100

3588

2563

8222

3278

1576

3638

Requirement for Nurses in 2001

(6 )

1~,900

6,734

16,711

16,865

3,485

1,998

1,496

14,837

16,601

17,487

38,646

7,262

7,111

15,603

24,608

20,144

23,138

18,410

The method adopted and the as~umptions made for fixinQ

the targeted nurse : population ratio for the year 2001 at

the national level and for each state are given below. It

may be mentioned that first the target for the 'National

Level' is determined and the same has been taken as 'Con-

trol' for the state-wise exercise on determination of target

for nurse population ratio and deriving therefrom the

~equirements of nurses:-

(i) At national level, a linear relationship between the

'time' and the 'nurse populat!on ratio' observed during

1981-1991 _ on annual basis was fitted; which yielded a

significant positive correlation of the order of

0.998426. The observed and expected value5 of the

nurse population ratio for the period 1981-1991 along

with the valu~s of the regression line are shown in

Table 10.3. Based on the same equation the targe~ed

nurse population ratio of '3638' for the year 2001 has

been derived at the 'All India' level.

(ii) The targeted nurse: population ratio Tor each state

has been determined by using two alternative

approaches. First, by applying the All-India

improvement ratio observed during 1991-2001 to the

nurse

second

. . population ratio of 1991 of each state and

by assuming the individual state-wise

improvement ratio during 1981-1991 to be valid for the

year 1991-2001. The approach which yielded a better

263

ratio for the year 2001 for a given state has be~n

adopted for that state. The exception to this approach

was the state of Kerala where the optimal ratio other

than 'better' is assumed as target for the year 2001'.

(iii)The figures of requirements tor nurses in 2001 tor

'other states and UTs' are derived as residual and

thereafter the nurse : population ratio is worked out;

which is quite consistent with the nurse: population

ratio figure of the previous years for this group of

states.

Nurse : Population Ratio in Urban Areas by States. J.991

The nurse population ratio is abroad indi~ator and

provides a crude index ot the extent at facilities ~vailable

in an area assuming an equal distribution of the available

facilities over locations/regions. Population density is,

in fact, a key variable in evaluating the adequacy of a

given ratio which is bound to vary from area to area. A

ratio might be reasonably adequate in an area where

population density is high but very inadequate where it is

very low. It may be mentioned that 901. of the nurses are

concentrated in urban areas because of the infrastructural

set up as most of the hospitals are located in metropoli5

and big c1ties. Table 10.4 below provides the population

per nurse for Total (Area) and that in urban areas along

with the percentage of urban population to total population

in each state.

264

Table 10.3

Comparison of observed values~f Nurse I Population ratio (pop. per nurse) with the expected values

derived from the regression lin~ during the period ),981 and 1991.

Year POQulation Qer Nurse Observed (yo) Expec.tad (ye)

( 1 ) (2 ) (3 )

1981 6308 6255

1982 6116 6123

1983 5985 5993

1984 5854 5862

1985 5706 5713

1986 ·5562 s600 "-

1987 5461 5470

1988 5345 5339

1989 5209 5208

1990 5096 5077

1991 4967 4946

Equation of the regress line :

y = a + bx

a = 6385.50909

b = -130.827

r = 0.998426

265

Table 10,.4

Population Der Nurse in tha States of India fgr Total and Urban areas, 1991

States Population per Nurse Total Urban

( 1 )

1. Andhra Pradesh

2. Assam

3. Bihar

4. Gujarat

5. Haryana

6. Himachal Pradesh

7. Jammu & Kashmir

8. Karnataka

9. Kerala

10. Madhya Pradesh

11. Maharashtra

12. Orissa

13. -Punj ab

14 •. Rajasthan

15. Tamil Nadu

16. Uttar Pradesh

17. West Bengal

(2 )

6,313

6,188

8,234

3,902·

7,407

3,968

8,083

4,790

2,509

5,862

3,069

6,842

4,488

4,899

3,499

11,319

4,475

18. Other States and 1,988 Union Territories

19. All India 4,967

(3 )

1,776

693

1,231

1,431

2,237

553

2,482

1,702

688

1,519

1,278

1,003

1,649

1,315

1,267

2,554

1,528

1,131

1,414

266

Percentage of Urban population to tot.l

(4 )

26.84

11.0.8

13.17

34.40

24.79

8.70

23.83

30.'¥1

26.44

23.21

38.73

13.43

29.72

22.88

34.20

19.89

27.39

54.79

25.72

.. ~'.

It is apparent from the Table 10.4 that situation in

respect of availability of nurses per 1000 population is far

better in urban areas. Particular reference may be made to

Kerala and Assam, where the situation compares well with the

situation prevalent in most. advanced countries.

These two states however present two typical ca~es.

Assam shows a higher/nurse population ratio in urban areas

because percentage of urban population to total population

-is very low only 11.081.; while Kerala, with more than one

fourth of the population in urban areas show the population

per nurse to be 2509 in rural areas and 688 in urban areas.

These ratios are nearly half of the All India average for

the both the areas being respectively 4967 for rural and

1414 for urban areas. This is because Kerala has the maxi-

mum population of nursing resources and as well produces the

maximum.

The states of U.P. and Bihar also provide a comparable

nurse population ratio in urban vis-a-vis the all-India

nurses but with marked rural/urban variations. This shows a

high concentration of nurses in urban areas inhabiting

relatively quite low proportion of population therein i.e.

19.891. in U.P. and 13.171. in Bihar. Himachal Pradesh also

presents more or less a similar case with very low percent-

age of population dwelling in urban areas; a marked varia-

tion between rural/urban nurse : population ratio but at a

lower scale as the nurse: population norm for hilly areas

are more liberal than plain areas.

267

METHOD II - Nurse: Doctor Ratio

The nurse: doctor ratio is often used as a basis for

estimating the demand for nurses. The norm of three nurses

per doctor has been recommended by all committees. Bhore

Committee had 'suggested the desirable- nurse population ratio

. . 500 and one doctor for 1500 population to be

achieved within a period of 15 years; which yielded a ratio

of three nurses per doctor. Th~ same was reiterated by

Mudaliar Committee in 1961; and even the latest staffing

pattern norm for hospitals by bed sizes provided by the

Bajaj Committee (1987) also yield an aggregative ratio of

one doctor to three nurses. >

An dttempt is made to work cut the requirements of

nurses on the basis of nurse: doctor ratio method. ThouQh

the various committees have recommended a doctor nurse

ratio Qf 1 : 3; yet the present ratio is very poor as can be

seen-from the Table below:-

Table 10.5. Doctor-Nurse ratio in the years

1971. 1981 and 1991 ----------------------------------~-------------~~---------Year Estimated stock of @ Nurse per doctor

Doctgr @ Nursesi (1) (2) (3) (4 )

------------------~----------------------------------------1971 123,500 72,303 0.59

1981 219,511 117,749 0.54

1991 310,673 184,779 0.59

Source : @ IAMR Working Paper No. 5/88 "Estimates of Stock of different categories of Educated Manpower upto 2001" - for doctors; i For Nurses - Section VI of this document.

268

It is apparent from the Table 10.5 above that there is

only halt-a-nurse per doctor. A decline in the nur?e . . doctor ratio during 1971-1981 points out to the situation

where~n the annual addition was more to the stock of doctors

than to that of nurses. Moreover, it is not appropriate to

relate the total stock of nurses with the total stock of

do~tors as a number of doctors also work as private practi-

tioners. On the other hand, majority of the nurses are

employed in hospital services as such the demand for nurses

can be related to the number of doctors who are employees.

The first step therefore in the exercise is· to estimate

the· number of doctor employees. The number of employee

doctors is not straight-away available from any source. For

this, the number of estimated doctors (total allopathic) for

the years 1981 to 1991 and 2001 has been obtained from

IAMR's publication entitled 'Estimates of stock of different

categories of educated manpower upto 2001". Further for

obtaining the component of employees do~tors, the data

available from the special Census reports have been used.

The report of 1981 Census on Degree holders and Technical

Personnel Survey provides a distribution of doctors (Allo-

pathic) according -to their present employment status. These

status are employed self-employed, trainee, retired, , . unem-

ployed and trying for job (unemployed) and not trying for

job and others. Excluding the categories 01 unemployed,

retired, trainees and others, the number of doctors enumer-

269

Year

(1)

1971

1981

1991

2001

ated as employed and self employed respectively are 45296

and 25204. This provide the relative proportion of employee

to the total doctors enumerated as workers 8S 64.251..

Similarly for 1971 this proportion was noted to be 70r.

thereby registering an annual decline by O.57"point (or 5.70

percentage point in decade).

Assuming the same decline trend~ the estimates of

doctors employee, for the years 19~1, 1991 and 2001 have

been worked out. The estimates of employee-

worked out are indicated in the Table below:-

Table 10.6

Estimated stock of Employees Qoctors in the years 1971. 1981. 1991"& 200~

doctors so

Estimated stocK of doctors P~rcEtntaCie I;If Le:stimated stgck Total Labour Force doctors emoloyee idoctors e[!l21Q:l'ee

in labour forCE (2 ) ( 3 ) ( 4 ) (5)

123,500 113,620 70.00 79,534

219,511 201,950 64.25 129,7~3

310~673 285,819 58.55 167,347

406,833 3'74.286 52.85 197,810

Q1

Sources 1. IAMR Working Paper No. 5/88.

2. Estimate of labour force stock of doctors have been worked out by assuming an LFPR of 921..

3. Special census reports on 'degree holders and Personnel'for the year 1971 and 1981.

4. For 1991 and 2001 - estimates on trend basis.

Technical

5. Derived by applying ratios of Col. (4) to the LF stock given in Col. (3).

270

Estimates of Requirements of Nurses for the Year

2001 based on the Employee Doctor: Nurse Ratio

The present situation with respect to the doctor-nurse

ratio is the outcome of the various policy decisions taKen

in the past under the then given resource constraint~

gave more emphasis to. the development of doctors - special-

ists ar.d thereby neglecting nurses. The staffing pattern

norms as recommended by the various committees from time to

time were never enforced.' Adequate ;,Limber-~of' -pos ts·-6T

nurses were never even sanctioned so as to be able to arrive

at the desired doctor: nurse ratio of 1:3. The require-

ments worked out by the Expert Committee/High POIt/er- Commit~-

tee, in fact, present this desirable number of n~rsing

. -

personnel which will provide the doctor:nurse ratio of 1:3.

In the present exercise, however, we have worked out _ ...

the requirements of nurses on the basis of following doctor!

nurse alternative assumptions i.e. nurse per doctor.

Assumption Nurses per doctor

1. Trend based Ratio 1.1-

2. Low assumption ... 1.5

3. Medium assumption 2.0

4. High assumption 3.0

The high assumption is the one which has been recom-

mended by various committees and the medium is the mid point

of the present ratio and high ratio. Loll" assumption

271

presents a mid point of the 'medium' and th~ present ratio,

the estimate of requirement of nurses under these assump-

tions along with trend based projection of requirements are

presented in the Table 10.7 below:

Table 10.7

ESTIMATED REQUIREMENTS OF NURSES IN 2OQ1UNDER ALTERNAiIVE ASSUMPTION OF DOCTOR. NURSE RATIO

Year Nurse per doctor Estimated of (employee . ) requirement

Nurses

( 1 ) (2 ) (3 )

1971 0.8 66,519

1981 0.8 108.330

1991 1.0 169,997

2001

Trend based 1.1 215~884

Low 1.5 296.715

Medium 2.0 395,620

High 3.0 593,430

The methodology under the 'trend based ratio' approach

was fitting a linear equation between the estimated number

of employee doctors and the estimated number of nurses in

labour force during the period 1981-1991 on annual basis and

using the same equation for deriving the requirements of

nurses for 2001. The equation yielded a significant

272

positive 'r' of the order of 0.994738. The expected and

obser0ed values of nurses and the nurse per doctor during

1981 to 1991 and that for the year 2001 are shown in Table

10.8 below:-

Year

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

2001

Table 10,8

Relationship between the number of employees doctors and the estimated labour force stock of nurses I dyring 1981-91

and the requirements for nurses for the year 2001

Percentage of - Number of Number of NUrse ~LF! -Nurse per doctor employees employee, Observed Expected doctor

to those doctors employed

64.25 129,753 108,330 105,412 0.83

63.68 134,105 114,197 112,47.6 0.85

63.11 138,516 119,247 119,636 0.86

62.54 142,627 124,588 126,309 0.87

61.97 146,615 130,570 132,783 0.89

61.40 150,206 136,851 138,612 0.91

60.83 153,716 142,350 144,310 0.93

60.26 157,187 148,487 149,944 0.95

59.69 160,618 155,544 155,513 0.97 .

5? .12 164,005 162,281 161,011 0.99

58.55 167,347 169,997 166,436 1.00

52.85 197,810 215,884 - 1.10

Values of the regression line are:-

a) = -105207.4238

b) = 1.623233

c) = 0.994738

273

The high

recommended by

ratio of 3.0 nurse :

various committees

doctor employees as

sets out the outer

desirable limit which may not be possible to achieve for

quite some time to come because the growth rate of the stock

of employee doctors and nurses is more or less similar. For

practical purposes, the demand estimates based on low as-

sumption of 1.5 nurse: dockor employee ratio should be

aimed at for the year 2001. Attempt should therefore be made

to fasten the pace of growth of the stock of nurses, and at

least the target ot 1.5 nurses per doctor under low assump­

tion should be achieved by creating adequate number of

positions for nurses.

METHOD III - Nurse: Expenditure Relationship

Under this method, the requirements of nurses are

worked out by relating them to the expenditure on Health/FW.

The provision of adequate financial resources is a prerequi­

site for implementing any programme of action to achieve a

certain goal. The nursing services are essentially an inte­

gral part of the health care delivery system and as such, it

is not possible to isolate this component in terms of either

its contribution towards the achievement of goal or its

relative share of available resource. Realising this, the

total expenditure on Health & F/W is taken as a parameter

for deriving the requirements of nursing personnel.

274

The requirement of nurses are, therefore, worked out by

relating the stock of nurses (LF) during 1981-1988 with the

actual expenditure of the corresponding period at 1980-81

price level through linear regression method. The tech-

niques yielded a positive 'r' value 01 0.993255. The ob-

served and" expected values of nurses for the period 1981-88

and the estimated values for the years 1996 and 2001 are

.indicated in the Table 10.9 below:

Expenditure on Medical' Health Servic~ during 1981-1988 (at ~980-81 price levell

~nd th~esti~ated expenditure during 1996 and 2001 alongwith the observed & expected values of nurses

Year EXQenditure on Medical and Heal th ~t 1980-81 ''r.> r1JuthJ 85 '- Qrices,

(1) (2 ) (3 )

Ac tua 1

1981 19, i04 108,330

1982 20,975 114,197

1983 23,787 119,247

1984 26,999 124,588

1985 28,001 130,570

1986 30,280 136,851

1987 32,592 142,350

1988 34,664 148,487

Projected

1996 69,081

.2001 99,184

The value 01 the regression line y = a + bx

a = 59995.45363 b = 2.52023720 r = 0.9932554

275

( 4 )

107~055

112~132

119,774

128,503

131,226

137,420

143,703

149,334

194,248

221,434

For working out the expected values of the expenditure

for the 2001, the value of GDP has been first e~timated by

applying the stipulated rates of growth during the forthcom­

ing period as given in VIII Plan document. The expected

values of expenditure on Health/FW in the years 1996 and

2001 are estimated to be 69081 and 99184 mi 11 ion f&>.nlspec­

tively With the regression equation which is obtained by

relating the values of expenditure on Health-& F/W ·with

those of GDP over the period 1981-1988, These have consti­

tuted respectively 2.51% and 2.69~ of the stipulated GDP

values as against the 2.04% observed in 1988. These per-

centages though still low but should be positively aimed at.

The relevant data are shown in the Table 10.10.

Table follows •••.

276

Year

(1)

1981

1982

1983

1984

1985

1986

1987

1988

1996

2001

Table 10.10

GD£_ .~ ~stant 1980-81 price level) during 1aa1 tQ laB-a and Uu.. th~ years 1illlli and_ 2illll alongH.ith Q~yJ:d

and e.xp~t&d values 2f Expenditu.r..e. on Health and ELL Percentage o.!. the. saJ1.e. t..o. GD_

GDP at constant 1980-81 price level Lin crores)

(2)

122,427

129,889

133,915

144,865

150,433

156,566/

163.271

170,205

275,633

368.l61

Source . .:.-

(In Rupees)

Expenditure (millions) % of health & F/M on Health and ELl expenditure ~Q GDf Observed Expected Observed Expected

(3) (4) (5) (6)

19,104

20,975

23,787

26,999

28,001

30,280

32.592

34,664.

19,236

21,663

22,973

26,536

28,347

30;343

32,524

34,780

69,081

99.184

1.56

1.S1

1.78

1.86

1.86

1..93

2.00

2.04

1.57

1.67

1. 72

1.83

1.89

1.94

1.99

2.04

2.51

2.69

(i) eso National Accounts Statistics 1992 - for the data on GDP during 1981-88.

(ii) The estimates of GDP for the years 1996 and 2001, have been· worked out by applying envisaged growth rates of 5.31% for the year 1992-93 and 5.61% for 1993-97 and 6.05% for 1997-2001.as available from the Eighth Five Year Plan document for different plan periqds.

(iii) Ministry of Finance, Deptt. of Economic Affairs for Expenditure on Medical & Health for the years

1981 to 1988.

(iv) For 1996 and 2001 derived through ·linear relation ship on GDP figures.

277

~THOD IV - CO~QQnent/Programmatic Approach

An examination of the employment and utilization

pattern of nurses indicat~s that nearly 901. of the nurses

are employed in hospitals and only 10% in the community

services under Rural Health Care Services.

In an institution like hospital, they are predominantly

employed

However,

overall

in functions relating to bed-patient care.

some of them are also engaged primarily in the

administration of the institution to. augment the

process ·of availability of adequate & timely nursing

services and as·such may not be directly engaged in bed-

patient care. But these do get counted under thR bed-

patient care while working out the nurse: bed ratio ba~ed

on the available stock of nurses in labour forc~. And the

bed nurse ratio so derived provides a relatively improved

ratio while in reality it may not be so. Therefore, in the

present exercise on estimation"of requirements, this func­

tion has been dealt with separately as a component.

Besides the bed - patient care, the hospitals are also

utilized as attached institutions to the training schools

for nurses to impart the practical aspects of the nursing

services. Hence some of the nurses with adequate orienta-

tion also function as 'faculty' in the training schools.

But this is also true that the entire faculty in training

schools does not essentially constitute of General Nurses;

these as well include the B.Sc(N)s, MSc(N)s, PHNs and even

from medicine and other related interdisciplinary areas.

278

.\ t..'!~.t' ..... \~ ..

It, therefore, becomes essential to know the requirements of

nurses for teaching activity. As supply pool-wise these

also flow from the same labour force stock of nurses and to

that extent the current bed nurse ratio becomes an over

estimate of the situation.

In the present exercise, therefore, we have attempted

to estimate the requirement of nurses for the following four

components:-

1. Bed Patient care

2. Administration ,

3. Teaching

4. Community Services.

The requirement of nurse~ for each of the component has

been worked out state-wise.

The requirements for bed patient care is worked out by

first determining the number- of beds in each state in the

yea~ 2001 and thereafter the requirement of nurses have been

derived by using appropriate nurses : bed ratio which was

determined separately in respect of e0ch state by consider-

ing the various related factors. The demand of nurses for

administration has been worked out by converting the number

of beds in each state in hospitals of different sizes and

the number of nurses required for administration in these

hospitals is derived by applying the suitable staff norms

available from technical report entitled 'Guide to staffing

pattern for hospitals in respect of ~uperintendents/Deputy

Superintendents/Assistant Superinte~dents matrons and Asst.

279

.' ~~~' .. ~: ., ~.

\

matrons etc., whose functions are primarily administrative.

The demand for nurses as teachers is wor~ed out by appor~

tion ing the tota I requi remen ts for teac hers, vJhic h have been

worked out by applying the teacher pupil ratio norm provided

by the Indian Nursing Council to the estimated admissio~s in

the year 2001. The requirements for nurses for Community

Health services are derived with the help of number of CHCs,

PHCs and sub-cen ter-s that wi 11 be avai lab 1 e in the ','.ear 2001

as per the population: institution norms and staffing

pattern norms provided by the Govt. of India in respect of

these different types of institutions. The projected popu-

. lation for the year 2001 by states is obtained from the

office of the Registrar General of India.

The results of this exercise are given in the summary

Table below presenting the estimated requirements of General

nurses for each of these components by states.

The methodological details and the assumptions made for

working out the requirements of nurses in the year 2001 for

each of these components are discussed in the following

paragraphs.

DEMAND FOR NURSES FOR BED PATIENT CARE IN HOSPITALS

The main problem in the context of working out requirements

of nurses for bed : patient care in hospitals is what targets tor

the year 2001 should be fixed for (i) bed: population ratio and

(ii) nurse: bed ratio. These two issues are the prime determi-

nants in estimating the nursing manpower demand for this segment.

280

~!,j.r~~ fp[ !'.~\~ I.,\D.~ CQnpq'}l;Ut AP.prQ9~b. :in 4~.1~ .

........ _-_ ....•.....................•...... _ .......•.•..•.. _ .... _ •....•. _ ..... -.-.... ---.----.. ---..........•. _ ... _---_._._--_.

Lnder hospital setting Ccmnunity services .. --..... - .. ----.-........ --~--.. --.

Bed Patient Admn. Teaching Total States Cal-e

e .... and Total

Col. (5) I!( ['...01. (6)

•• M •••••• ___ • ._-'-- '--'-- ..... -_._ .. __ ......... _ ....... _.- _ ..... _--_ .. _--(2) 0) (4) (5) (6) (7)

.1. Pnclhl-a Pt-adesh .15,9::() 275 68 16,273 5258 21~ 5.31

. ..., As~;;am 4,466 .106 27 4,59'1 2826 ]~425 .'::'cr -

-:r ... ' . 8.ih",\!- 14,116 Z:'.1 77 14,424 9102 23~526

4. aljal-at 14~624 265 28 14~917 3195 18,112

5. Hal"yana 3~781 57 Z~ ~:.,860 1221 5~(l81

6. Himachal PI-ade<.5h 877 49 11 9'."57 726 1~66.3

7. 1~:r..~I-n.::\tal·;.a 13,777 :: . .'96 87 14,160 ::!3:~1 17,481

8. Ji::\ITlm..1 11< 1<,,:'1sl-vnil- 1,083 ':(1 1,113 890 2~O(l3

9. I:::el-ala 11,396 5.16 146 12,05f3 2615 14,67.'::'

10. Madhya F'I'-~\de!:;h 17,066 16<;> 57 17,2:.>2 5985 23~277

11. Mahal-ashtn:'I ::0,407 608 ~ 220 31 ~23t:\ 5184 :.::.6,419

12. Ot-issa 4,400 107 24 4,5.31 3114 7~645

.1:~ .. F\.\njab 5,0::8 102 25 5,165 1354 6~519

14. Pajasthan .11,583 146 7.1. 11 ,8(l(1 ~O 16,4:::'~)

15. Tamil l\!adu 21~1)23 3r16 12:i 21~:i44 4()(1:2.~ 25~547

.1.6. Utt.al- PI'"adesh 21~295 41:i 82 21~ 7r:r2 11~780 ~~!l572

17. West Bengal 19~5(13 4:3'~) 85 20,CI.18 5,815 25,833

18. Othe .... States & 16,582 271 .110 .16,96~:: .1~282 18,245 Union Ten-i to .... ies

_____ • .,M ._. __ . _.~ .... _ .. _H'_~ ..... __ . __ ._----------_ .. _----_ .. -19. All India 2~26~947 446':1 1265 232,681 72!1~.().t :XI4~982 .. ---, ..... --~., ....... - ...... -.... , .... " .. - ... ----.. - .. -_ ..... _ .. _._-_ ... _----_ ........... _ ..•......• --_ ..... _._ .... _. __ .. __ .. _-_ ....... __ ..... _-_ .... __ .. _._ .. _ .. __ ._:_--_ .. -

281

BED : POPULATION RATIO - TARGET FOR 2091

The bed : population ratio a~ observed during the past

three decades along with the feasible targeted ratio for

2001 may be seen from the Table 10.11 below:-

/

Year

( 1 )

1946

1961

1971

1981

1991

2001

Table 10.11

Bed : Population Ratio at decennial intervals during 1946 an9 1961 to 1991 and for 2001

Number of Beds Beds per 1000 population

(2 ) (3 )

73,000 0.24

2,26,550 0.-52

3,48,6'55 0.64

4,66,677 0.68

6,19,433 0-.73

7,77,-:<95 0.79 @ (0.7688)

Source: (i) Health Statistic of India, 1961, 1971 and 1981

(ii)Health Infor~ation of India, 1991;

(iii)Report of the 'Health Surv~y' & Development Committee, 1946;

@ Determined on the basis 01 statewise trend.

It will be seen from the Table 10.11 that despite a

significant increase in the absolute number of beds, the bed

population ratio has not increased in a marked way 0fter ,

1971; as the given increase could not commensurate wi~h the

282

growth of population" Now the question arises what should

be the target for "2001?

Bhore Committee in 1946 had suggested 20 - 30 beds per

10,000 population as a short term measure and 50-60 beds as

a long ter~ measure to be achieved by the lQ76. Mudaliar

Committee however suggested 10 beds per 10,000 population to

be achieved by in a period of fifteen years again upto 1976.

The current sit~ation reveals that although the bed popula­

tion ratio has gradu~lly improved to 0.74 in 1991, yet "it is

far below the desired ratio of one bed per 1000 population.

Now should this be taken as a target to be achieved by the

end of the century.

The fixation of target with respect to the bed: popu­

lation ratio is certainly a complex exerc~se which needs to

take into consideration various factors like the population

to be served (i.e. rural/urban); regional variations,

Govt.'s health plans, the available logistics and ma~power

and above all the financial implications of the entire

package of services needed for an adequate patient care.

The indoor patient care is provided through provision

of beds in different hospitals. The hospitals vary in size

the smallest being with less than 25 beds and the target

with a bed facility of more than 700 beds. The population

of hospitals with largest beds facility (i.e. with 750 or

more) is only 1% but these account for more than 20% of the

total beds since these big hospitals are usually functioning

in big cities and metropolis. The bed population ratio in

283

urban areas is 2:9 per 1000 population as aQainst the over-

all average bed: population ratio of 0.74 in 1~91.

The Government of India has set a target for one bed

per 1000 population to be achieved by 2001. an

additional provision of 366,669 beds during 1991-?000. In

1991, the number of beds available is 619,433. Is it faas;i.-

ble to aim at a target of one bed per 1000 population just

in a period of less than one decade? Even for maintaining "

the present ratio of 0.74 beds, a provision of about

1,10,000 (one lakh ten thousand) beds i~ needed. There is

also a problem of availability of adequate funds needed for

the entire package of hospital services.

Not only this, under the New Health Policy, there is

shift in the approach under the primary health care ap-

proach. Provision of adequate preventive & promotive serv-

ices takes an overriding priority over the hospital based

care centered services. As such the emphasis is more on the

provision of facilities like safe drinking water, environ-

ment"al sanitation, improvement in nutritional levels and

enhancing the general awakening of the masses through ade-

quate health education measure~.

Besides there also exist large regional variations. In

1991, the bed-population ratio in the U.P., Bihar and M.P.

is only 0.3 per 1000 population while this is noted to bm

2.4 in Kerala followed by 'UTs and other states' with 1.6

bed population ratio. Maharashtra has a bed population

ratio of 1.4 and the Gujarat 1.1 i.e. above the All-India

284

average level,- In view of this}the need is to address· ~uch

issues like eliminating regional variations between states

and among location (R/U) not only in terms of the number of

hospitals but as well in terms of the provision 01 adequate

incumbent of staff, equipment, infrastructure and other

logistics.

So the question arises what ratio should be fixed for

the year 2001? In the present exercise, therefore, instead

at fixing an aggregated bed : population ratio at the na-

tional level, attempt is made to determine this ratio for

each s~ate independently studying the trends of performance

in the last decade in conjunction with other factors like

percentage ot urban population; character of migration and

available nurse : bed ratio.

Based on this method, a pragmatic target of 0.789 beds

per 1000 population at All India level has been obtained by

adding the number of beds derived for each state on the

basis of the ~espective targeted bed population ratio

~pplied to the projected population of the corr@sponding

state for the year 2001. Detailed state-wise discussion on

determination of bed: population ratio follows later.

Nurae -Bed RatiQ: Target tpr 2001

Table 10.12 below provides the number of beds, the

number at nurses in hospitals and the beds per nurse during

the period 1961 to 1991 at decennial interval. Data regard-

ing nurses in hospital is not,available. It is herein

285

assumed that all nurses in urban areas are ~mployed in

hospitals.

Jable 10.12

Number of h~~Rital beds, NurseSand the beds oer Nurse in the years 1961. 1971. 1981, 1991

-----------~-----------------------------------------------

Year Number of hospital - beds

Number of Nurses in hospital

Beds per nurse

-------------------~-----------~--------~-~--~-~~------------1

1961

1971

1981

1991

2001?

2 3 4

226,550 31,640 7.2

348,655 63,425 5.5

466,677 101,061 4.6

619,433 153,549 4.0

Source: (i) Health St~tisticSof India, 1961, 1971 and 1981

(ii) Health Information of India, 1991.

Now the question arises what should be the target for

The quality of the nursing service depends upon the

adequacy of the number of nurses provided in consonance to

the minimum number as per the staffing pattern norms laid

down by professionals at different points of time.

BesidesJ the standard staffing norms, work load is also

one of the important consideration for determining the

requirement of nurses; which varies widely from area to area

depending upon the pattern of bed - utilization in a given

area.

286

However, despite wide regional variation ~~ith respect

to the bed-utilization pattern, it is widely believed that

nurses are over-burdened and the load is too heavy to do

justice to their work. In this context, the High Power

Committee on Nursing and Nursing Profession has observed

that "Although the overall ratio of nurses to hospital bads

is 1 : 3 in the Central Government institutions and 1: 10

in U.P. & Bihar; yet in actual practice it was observed that

a nurse looks after one or even two wards of 50 - 60 pa-

tients during evening and night shifts.

nel are distributed in various OPDs,

The nursinQ person­

QTS and Special

Units. It was revealed that on an average nearly 1/3 is on

leave or absence etc. and only 1/3 is available for the bed

side care. All these factors lead to poor nurse - bed ratio

in the wards and an increased work load".

This entire situation therefore evan ra~ses question

about the fixing of staffing pattern norms. The norms so

far recommended by 'various Committees at different points do

reveal certain variations.

As early as in 1946, the Bhore Committee has recommend­

ed nurse strength of 20 for a 75 bedded primary unit; 180

for 650 b~dded secondary unit and 875 for 2500 bedded in

district hospital. In 1954 the Shetty Committee recommended

a nurse bed ratio of 1 : 3 in the teaching hospital and that

to be l' ; 5 in' non~teaching hospitals. The same ratio was

later reiterated by Mudaliar Committee in 1961. These

287

ratios did not take account _ of the re_Quirements for shift

duty and leave reserves etc.

Later in 1968, Hospital Review Committee (Iyer Commit­

tee) provided elaborate staffing pattern for hospitals ot

different size~ and suggested that 10% of the beds should be

reserved for emergency. It also suggested to take note of

the three shifts in which nurses attend the duty in the

wards meaning thereby trebling the requirements. It means

for Intensive .Care Unit (leU) there should be three nurses

for one bed to provide 24 hours duty. For OPDs, the Commit-

tee3uggested one nurse for 100 out-patients. The recommen-

dations of the Committee were more or less similar to the

norms prov~ded in Technic~l Report No.1 of NIHFW entitled

'Guide to staffing pattern for Hospitals'.

It is worth mentioning here that each subsequent com­

mittee has provided the nurse bed ratio norm as an improve­

ment over the previously recommended norms without going

into the analysis of the then existing situation , reasons

for that and to suggest measures~ ~or optimizing the health

service system other than improvement in staff norms.

The latest attempt on this aspect Was Cadre Review

Committee (set up in 1988) referred to in the Report of the

High Power Commi t tee on !'L.Jrses & _ Nursing profession. This

Committee had evolved staffing pattern norm for a 500 beds

hospitals as follows:-

288

1. Nursing Superintendent

2. Oy. Nsg. Superintendent

3. Asst.Nsg. Superintendent

4. Nursing Sisters

5. Staff Nurses

Total

1

1

9

54

335

The High Power Committee 1989 in their Report has pro­

vided a 'perspective on staffing norms'. Relevant extracts

from the report are given be}ow: (pp.21-22)

"A study of these norms reveals that in the first in­

stance no State has implemented even the norms set out 3S

years back. The suggested norms do not specify coverage of

Nursing services for 24 hours for 365 days in a year. It is

observed that a regular full time employed nurse works for

only 48 - 52 hours a week. She gets 72 days off in a year,

12 . days' casual leave and 30 days Earned leave (Total 114

days) which means she works only for 231 days in a year

(365-114). Hence, for every nurse there is need for 1: 1.3

nurses. In other words, operationally four nurses are

required in place of 3 nurses. Nursing manpower requirement

has to meet the ~ursing service needs of 365 days in a year

and 24 hours a day, whereas the nurse works only for 8 hours

a day or night for 231 d~ys. The situation varies from

Statl~ to State.

289

Further, the needt of patients vary according to the

level of dependency or seriousness of sickness. Several

time and activity studies have revealed the actual require-

ments for basic nursing care of the minimum standard depend-

ing on the degree of the patients' illhess, i.e. completely

dependent, partiaily dependent and ambulatory. For the

former t00 categories the manpower needs are much greater

than a~y norms described above. It has been stated in one

study conducted at the AIIMS' that for a total of 749 pa-

tients, 629 nurses were required (study dane in 1981).

Including the staff for various departments and the leave

reserve, 775 nurses were actually needed for 749 patients.

Keeping in view all factors, i.e. assessment of nursing

service status, _quality of nursing care provided, con-

straints of training of manpower and financial limitations,

the High Power Committee recommends the following norms,

already suggested by the Bajaj-Committee for Hospital Nurs-

ing Services for Urban Areas.

1. Nursing Supdt. 1 200 beds (hospitals with 200 or more beds)

2 Dy.Nsg. Supdt. 1 300 beds (wherever beds are over 200)

3. Asst.Nsg. Suipdt. 1 150 beds (wherever beds are over 1:50)

(7 . 1000 beds) . 4. t.Jard Sister/Ward 1 25 beds + 30Y. leave

reserve Supervisor.

5. Staff Nurses for 1 3 (or 1 . 9 for . each shift) + wards 30% leave reserve

290

6. Fo~ Nu~ses OPD &

7. For Intensive Care Units

8.. For specialized De­pa~tments such a~ Ope~ation Theat~e,

Labou~ Room etc.

1 : 100 patients (1 bed: 5 out Eme~gency etc. patients)

30% leave ~ese~ve

1 : 1 (or 1 I 3 for each shift) 30% leave ~ese~ve

1 : 25 + 301. leave ~eserve

F~om an analys~s of the .above discussion, on the basis

of the staffing pittern no~ms ~ecommended by the various

Committees, from time to time, the overall nurse: bed ratio

wo~ks out to be as follows:

'Beds Per Nurse' as recommended

by various Committees

Committee

1. 8ho~e Committee

2. Ea~lier Committee/NIHFW

Publication

3. Expert Committee

4. Cad~e Review Committee

5. High Powe~'Committee

6. T~end based:

1981

1991

2001

. .

Bed Per Nurse

3.0

2.5

1.49

1.49

1.49

4.6

4.0

3.4

In the p~esent exe~cise, we have therefore attempted to

wo~~ out the ~equirements of nurses "n~e~ these alternative

291

sets of staffing pattern norms suggest~d at diff~rent points

of time taking the present availability of beds in the

hospitals and the estimated number of beds for the year

2001. Table 10.13 below provides these alternative require-

ments vis-a-vis the actual position with respect to the

nurse bed ratio.

Table 10.13 Requirements of Nurses (Hospitals) for the years 1981, 1991 and 2001 on the basis of (i) actual

(Trend basis) (ii) Bajaj Committee (1987) norms and (iii) earlier norms of staffing pattern for hospitals

by size of Qed capacity and (lv) the Bhore Committee Norms

( i ) Beds per 1000 population

( i i) Number. of Beds

(iii) Estimated req­uirements of nurses on the basis of:

a) Bed nurse

Year

-1981 1991

0.683 0.734

466,677 619-~ 433

ratio. 101,061 153,549 (Actual)

b) Expert/HPC Committee 312,988 415,438 norms (1.49)

c) Earlier Norms (2.5) 186,671 247.773

d) Shore Commi-ttee norms 155,559 206,478 (3.0)

292

Target for 2001

0.789

777,792

226,947

521,645

311,117

259,264

It would be seen from the above table that most moderate

norm of the 3 beds : per nurse set as target for the year

1976 by Shore Committee has not been achieved even by 1991.

The actual number of nurses available for urban hospitals is

yet 153,549 as against the number required by this moderate

ratio to be 206478. The question now arises what target

should be fixed for 2001, keeping in view the pattern of

past performance, and the current situation and feasibiliky

aspect conditioned by several other factors.

Therefore,in the present exercise instead of fixing an

aggregate nurse bed ratio at the national level, we have

attempted to determine the bed: nurse.ratio for each state

individually keeping in view the past performance, in re-

spect of the availability of nurses; the respective percent­

age of nurses in the urban areas and the re~pective percent­

age of urban population in each state.

The methodological details of the present exercise are

elaborated below taking the each state as individual case:-

METHODOLOGICAL DETAILS FOR FIXING STATEWISE TARGETS OF BED

POPULATION RATIO AND NURSE BED RATIO

In the present exercise, the number of beds for the year

2001 ha~ been first determined for each state independently

looking at the trends in the past performance over the last

two decades; these are later translated into requirements of

nurses by applYlng appropriate~nurse ratio fixed separate­

ly for each 'state on the basis of past trends and various

293

indi~ators developed for the purpose.

The underlying consideration for determining the bed

population ratio and the nurse : bed ratio for 2001 for each

state, besides the past performance, were other factors like

percentage of urban population, the urban nurse population

ratio, nurse: bed ratio and the absorptive capacity of the

state i.e. whether in-migrating or out-migrating etc. The

national level requirements are thereafter deriv~d "as the

total sum of the individual states' requirement. The rele-

vant data on these parameters for the year 1991 is shown in

the Table 10.14 below:-

Teble 1Q.14

Statewiag data !Z! bed§ Del' .1,000· oowlAtigJ {Rural ~ Urbanl Powlati!il} cer ~.

M,!gr!1tig) rates l Pen:entaae 01 Urban ooouletion to total DODUl!1tia1

19r the vear :1:991 and the taroe:!;;ted Bed : coculatig) and NJrse: Bad !:at:i,g fg: 2001

Beds per 1000 Beds per Population Migration Yo of Targets State lJ.5til a tioo nurse ger f\l1rse (-)/(+) Urban for 2001

oar Od5an Total Ufbaii popu- eeds NJrse lation per -bed

1()(x) popu-popu- lation

(1 ) (2) (3) (4) (5) (6) (7) (B) (9) (10)

A.P 0.5 2.0 3.6 6,313 1776 + B.36 26.84 0.65 3.0

Assam 0.6 5.9 4.1 6,188 693 - 42.19 11.08 0.6 4.1

Bihar 0.3 2.5 3.0 B,234 1231 + 34.62 13.17 0.4 3.0

G.\jarat 1.1 3.3 4.7 3,902 1431 + 3.89 34.40 1.1 3.5

Haryana 0.4 1.7 3.9 " 7,407 Z237 - 68.73 24.79 0.6 3.0

H.P. O.B 9.6 5.3 3,968 553 + 82.62 B.70 O.B 5.3

J & K 1.1 4.5 11.1 8,083 2482 + 100.51 23.83 1.1 9.0

Kama- 0.8 2.5 4.2 4,790 1702 - 1.33 30.91 0.9 3.4 taka

Table contd •••

294

Table cc:ntd .•• (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

Kerala 2.4 9.2 6.3 2,'XJ9 688 - 46.55 26.44 2.0 6.0

M.P. 0.3 1.4 2.2 5,862 1519 + 35.89 23.21 0.5 2.2

Maha .... a-shtra 1.4 3.7 4.7 3,069 1278 - 27.49 38.73 1.4 4.0

Or-issa 0.4 3.3 3.3 6,842 1003 + 18.07 13.43 0.4 3.3

Punjab 0.7 2.5 4.1 4,488 1649 - 246.96 '29.72 0.8 3.5

Rajas-than 0.5 2.2 2.9 4,899 1315 + 43.66 22.88 0.6 2.9

Tamil Nadu 0.9 2.6 3.2 3,499 1267 + :28.tn 34.20 1.0 3.0

U.P. 0.3 1.7 4.4 11,319 2554 + 7.53 19.89 0.45 3.5

W.B. 0.8 2.7 4.4 4,475 1528 + 16.43 27.39 0.9 3.5

U.Ts & other States 1.6 2.9 3.3 r,988 1131 - 21.17 54.79 1.6 2.8

All 0.74 2.9 4.0 4,967 1414 13.27 25.72 0.79 3.4 India

The details of the fixing targets in re~pect of Bed

population ratios and the nurse:bed ratio for each stat~ are

elaborated below. It may be ment~oned here that All-India

Average was taken as the ·Standa .... d Point', and the pOSition

in respect of each state has been studied in terms of its

deviation (~) from the All India Ave .... age.

A table cross-classifying different state~ in to three

broad range-groups according to population pe .... nu .... se And the

beds per 1000 population is presented below. The middle

group, however, presents the 'A~l-I~dia Standard' which only

has the state of ·Punjab'. The states of Karnataka and

295

W.Bengal, though in the middle ranges according to popula-

tion per nurse range show a high bed : population range and

hence the beds per nurse are higher which exhibit a need to

increase the number of nurses and not beds.

Tible 10.15 A Cross classific@tion of Stites by Population

per nurse and the n\..ll'llber of bed'! per 1QOQ pop..llatigJ in 1991.

States having populatiCCl per nurse

1 ess than 4O(X) 7YXXJ

Population I;~r nurse Bed per 1000 pQp.!lation

(a) (b) (c) 4000-6000

--(a)- -(b) (c) (a) (b) (c)_

(1 )

Above 0.8

0.6-0.8

less than 0.6

B."darat

H.P ..

Kerala

Maha­rashtra

3902,

3968,

2'XJ9,

3069,

(2)

1.1, 4.7

" 0.8, 5.3

2.4, 6.3

1.4, 4.7

Tamil- 3499-, 0.9, 3.2 Nadu

Other states & 1988, 1.6, 3.3 UTs

Kama- 4790, taka

West 4475, Bengal

Punj ab 4488,

M.P. 5862,

Rajas- 4899, ,,",Cl.~

f\bte. ( a) Popul ation per r-tJrsa

(3)

0.8,

0.8

0.7,

0.3,

0.5,

(b) Bed per 1000 populatiCCl

( c) Beds per nurse

296

(4)

4.2 J & K 8083 1.1,11.1

4.4

4.1 Ai;sam 6188, 0.6, 4.1

2.2 A.P. 6313, 0.5, 3.6

2.9 Bihar 8234, 0.3, 3.0

Hary- 7407, 0.4, 3.9 ana

Or-.issa 6842, 0.4, 3.3

u.P. 11319,0.3, 4.4

T~e following inferences can be drawn out ot the above clas-

sificatory frame to plan the future cou~se of determining targets

with respect to bed : population ratio and nurse: bed ratio

Table 10.16

Salient Inferences Reaarding the Status of Nursing Personal in Qjj1erent States

----------------------------------------------------------------. .

8ed per 1000 population

Good

Popu I ation per Nurse,

Good

Only beds per nurse to be seen to know the kind of change

Satisfactory

Only beds per nurse to be seen to spell out the kind of change needed

Poor

Nurses to ba. increased nemarkabl y and not bed$

Satisfactory Both the parameters should be improved simulta­neously to maintain the existing average.

Poor Beds need to be increased

Bads per 1000 population need to be increa$ed signi­ficantly

Beds and nurses both

11.e.e.c(. ~~. . to be increased to come up to All-India level

The details in respect of the each state regarding the

fixation of targets shown in Table 1'10.10.12 is provided

below in the following paragraphs.

The analysis for each of these states which is attempted

v.~eping the trend of past performance in relation to the

All-India averages as norm for them follows:

Andhra Pradesh - Higher population: nurse ratio and

the lower bed population ratio indi-

cate that beds and nurses both are

297

2. Assam

3. Bihar

4. Gujarat

less; which has resultad into a

lower nurse-bed ratio; there is in-

migration while the relative

tion of urban population is

propor­

higher;

there is scope of improvement in the

situation hence a higher bed popula­

tion ratio (0.65) as well a higher

bed nurse ratio 3.0 fixed for 2001.

A very high concentration of nurses

in urban areas; it is an out

migrating

bed per

reasonable,

state, bed per nurse

1000 population

no need to increasQ

and

also

the

nurses - therefore maintained at the

level of 1991.

Beds less, nurse less and therefore

higher population per nur$es; urban

population less and therefore better

nurse population ratio; in urban

areas, state is also in-migrating

during the last

performance on bed

decades,

population

the

has

been negative, therefore, n~ed to

increase beds avoiding concentration

in urban areas with corresponding

increase in nurses maintaining the

same nurse - bed ratio.

Beds more than All India J Nurses

more than adequate, hence th~ same bed

298

s. Haryana

6. H.P.

7. J & K

8. KarnataKa

population ratio and the All-India

nurse bed ratio maintained for 2001.

Beds less, nurses less, an out

migrating state; there is a need to

increase the beds significantly so

that nurses are internally employed

by curtailing out migration and with

improved nurse bed ratio. Hence.

impro'i.ed bed: ~opulation ratio and

an improved nurse bed ratio for 2001.

Nurses and beds both adequate better

than All India average due.to liberal

norms being a hilly area - the state

fulfills its demand by in-migration;

hence the 1991 level ot bed;

Population ratio and the nurse bed

ratio assumed for 2001.

Beds 'adequate but nurses too less ;,

cent per cent in-migration, therefore

the bed : popul.tion ratio maintained

at the same level with improvement in

nurse bed ratio from 11.1 beds per

nurses in 1991 to 9 beds in 2001.

Although aggregate bed population

and nurses: bed ratio are more or

less equal to the All-India average,

yet with a higher proportion of urban

areas, the situation in urban areas

is not in accordance to the national

299

level; the st~te is outmigrating too;

hence a better bed population ratio

and improved nurse bed ratio for 2001

is targeted so that nurses are

internally absorbed.

9. Kerala Remarkably better than All India

aver-age in every respect; an

outmigfating state; the question of

bed-utilization is '1er" r. pertinent;~

hence the bed population ratio fixed

at 2.0 for 2001 as against the 0.8 at

All India level and its present ratio

of 2.4, and the bed nurse ratio fixed

at 6.0 against the present ratio 6.3:

so that more of nurses could be

internally absorbed.

10. M.P. Beds too less and also less nurses in

terms of population nurse ratio but

adequate enough for beds, an in-

migrating state, a substantial

improvement is suggested in bed-

population ratio i.e. 0.5 from the

current ratio of 0.3 with the same

nurse - bed ratio of 2.2 in 2001.

11. Maharashtra Bed population ratio better than All

India average; bed per nurse however

slightly higher but number of nurses

adequate as per the population norm;

an outmigrating states; for 2001 same

300

12. Orissa

13. Punjab

14. Rajasthan

bed population ratio is suggested

with an improvement for bed: nurse

ratio.

Aggregatively, Beds too less but

largely concentrated in urban areas, . less nurses in terms of population . -

nurse ratio but adequat~ for the

number of beds, an in-migrating state

the proportion of urban population is

small, hence, with the same number of

beds; it would serve better if

diverted to rural areas; therefore

targ~t suggested for 2001 is the same

that observed in 1991.

Situation more or less similar to

that of All India average both in

terms of bed population ratio and bed: n..urS ..... ~atio an outmigrating state -- there-

fore all India average for 2001 assu-

med for this state in tErms of both

these parameters Le. 0.8 bed popula-

tion ratl0 and 3.5 bed per nurse.

Beds less, less nurses in terms of

population nurse ratio but adequate

enough for beds, an in-migrating

state, an improvement suggested in

bed - population ratio i.e. 0.6 from

the current ratio of 0.5 with the

same nurse bed ratio of 2.9 in 2001.

301

15. Tamil rladu

16. U.P.

17. West Bengal

Slightly better than All India

average a balanced situation in

terms of bed population ratio, bed-

nurse

ratio,

ratio and nurse-population

hence the target for 2001

fixed with slight improvements like

1.0 bed per 1000 population of 0.9

the present level and 3.0 bed nurse

ratio as against the present ratio of

3.2.

Number of beds too less; the nurse

also too less in term's of population

per nurse but relatively enough tor

the number of beds and the number 01

beds per nurse is 4.4 as against the

all India average of 4 beds per nurse

- there is need to increase both -the

number of beds as well as nurses

the target for 2001 fixed as 0.45

beds per 1000 population and the bed

: nurse ratio at 3.5.

Slightly better than all India

average a balanced situation in

terms of bed population ratio, bed

per. nurse and population per nurses -

hence target for 2001 fixed with

slight J~provements both in bed

302

lB. lI.Ts. &

other States

population ratio and bed per nurse to

Gommensurate

improvement.

with all India

The ratio of beds per

1000 population fixed at 0.9 as

against the present ratio of 0.8 and

the b'eds'per nurse at 3.5.against the

present rat.o of 4,.4.

Better than all India average in all

respects i.e. bed per 1000,

population, bed per nurse and

population per nurse -- targets for

ratio of bed per 1000 population

maintained at the present level for

2001 and for bed nurse ratio a

slight improvement assumed ~.e. 2.8

as against the present ratio of 3.3.

Based on the targets so determined, the figures of the

likely number of beds in 2001 and the number of nurses that

will be required to man these beds are shown in the Table

10. 17 below:-

Table follows ••••

303

Table 10.17

Estimated number of beds and the requirements of Nurses by States. 2001

States No. ot-Beds Regu,irements Q1

1. Andhra Pradesh 47,790 15,930

,., Assam 18,31£1 4,466 ......

3. Bihar 42,348 14,116

4. Gujarat 51,184 14,624

5. Haryana 11,344 3,781

6. Himachal Pradesh 4~646 877

7. J~)y'\1YIu... ~ kabh,')"y\~ - 9,745 1,083

8. 'k 0.. "'-,.,.0. ~«l ~ct 46,842 13,777

9. Kerala 68,378 11,396

10.Madhya Pradesh - 37,546 17,066

11 '. Maharashtra 121,626 30,407

12. Orissa 14,520 4,400

13. Punjab 17,634 5,038

,14. Rajasthan 33,590 11,583

15. Tamil Nadu 63,070 21,023

16. Uttar Pradesh 74,531 21,295

17. West Bengal 68,261 19,503

18. Other States & 46,430 16,582 Union Territories

19. All India 777,795 226,947

304

Nurses

The above method of fixing ta~gets for nurse-bed ~atio

and bed population ratio fo~ each state duly examining the

related pa~amete~s no doubt is better approach than the

deriving ~equi~ements on the basis of global ~atios, yet it

leaves much to be desi~ed. The ~equi~ements of nurses and

the provision of beds taKe place in an institution called

'Hospital' which a~e of diffe~ent sizes and employ diffe~e~t

cadres of nu~ses. Obviously, the ~equirements of nu~ses fo~

beds would not be at simila~ scale in the hospitals of

different sizes. Unless base line data showing the deploy­

ment of nu~ses in diffe~ent sizes of hospitals is known such

an exercise cannot be unde~taken due to lack of adequate

informational base.

For Administration

The staffing patte~n no~ms p~ovided in NIHFW is Techni­

cal Report No.5 entitled "Guide to Staffing Pattern for

Hospitals" and ~hose provided by the previous committee e.g.

Committee, enlist ce~tain posts of Superintendents,

Deputy Superintendents/Matron, and Assistant Supe~in-

tendents/Assistant Matrons fo~ diffe~ent sizes of hospitals

in addition to the la~ge number of posts for Siste~ In­

Charge/Wa~d Sisters and Staff Nurses.

In the hiera~chy of positions, the incumbents at Supe~-

int-enden t/Depu t y- Superintendent/Assistant Supe~inten-

dent/Matron/Asssitant Matrons levels are not supposed to be

305

di~ectly engaged in the bed-patient care. Their job is mo~e

to facilitate the smooth functioning of the institution

through ensuring adequate and timely supply of nursing

services in different wards. As such these categories in

the p~esent exercise are taken under Administration.

To work out the requirements for these categories at a

future date, we need information regarding likely number of

hospitals by sizes in the year 2001. The data on number of

hospitals by size of bed-capacity are available for the

years 1979, 1983 and1987. The trend in the change of dis­

t~ibution over these periods has been studied and the same

has been used fo~ estima~ing the numbe~ of hospitals by bed

size capacity in the 2001.

Fo~ this,fi~st, the estimated number of beds a~e dis­

tributed over the different size of hospitals based on the

stipulated distribution for the year 2001 and then by apply­

ing the average bed size in each hospital size group the

number of hospitals of different sizes have been obtained.

Applying the recommended norms for the above mentioned

categories of personnel to the numbe~ of hospitals of dif­

ferent sizes, the requiremenf of these cate~ories have been

worked out.

Following steps were involved in the process of obtaining

the number of hospitals with different bed-size in 2001 and

the~eby de~iving the requi~ements of nu~ses for administra­

ti'"e posts:-

1. Estimating the requirements of beds by 2001

306

2. Converting the beds into the size of hospitals

3. Estimating the number of hospitals by beds capacity

4. Estimating the statewise number of hospitals by bed

capacity sizes.

5. Estimating the requirem~nts of 'Nursing pos~s' for

Administration in the estimated number of hospitals.

Methodological details of each of the above mentioned

steps are discu.·ssed below:-

1. Estimating the Requirements of Beds by 2001.

The number of beds for the year 2001 are estimated by

estimating a bed population ratio as 0.789 per thousand

popu I a tion • This ratio has been obtained as an aggregate on

the basis of the past performance in each of the state; as

explained earlier under the estimation of nursing require­

ments for bed-patient care.

2. Converting the beds into the size of hospitals

The information with regard to the number of beds by

size of hospital have been obtained from the of Ministry of

Health, publication, entitled "Health Information of India",

previously known as Health Statistics of India of the years

1979, 1983 and 1987; which are shown in the Table 10.18 •

..

Table follows ..... .

307

Table No.tO.tS

Number of Hospitals by size of bed capacity and the number of beds therein: 1981, 1983, 1987.

Bed Capacity

1

2:5

26-50

51:-75

76-100

101-200

201-300

301-400

401-500

501-600

601-700

701 +

1979 No. of-- No. of Hospitals Beds

2 3

2,799 35,393

1,243 46,977

366 23,133

322 29,648

514 74,257

193 47,596

81 28,173

5-4 24,449

34 18,907

36 23,377

88 89,744

1983 1987 No. 01--- No. of No. of--No. of Hospitals Beds Hospitals Beds

4 5 6 7

3,958 47,073 5,799 65,791

1,522 56,449 1,805 66,087

407 25,434 466 ·28,717

378 34,377 407 37,791

564 82,880 611 89,816

227 56,518 240 62,761

97 33,655 105 36,879

50 22,727 57 26,567

38 20,756 42 25,256

36 23,494 40 26,116

104 106,789 105 110,874 -----.--------------------------------------~---------------------Total ( All India)

5,730 441,654 7,381 510,152 9,677

Source: 1. Health Statistics of India, 1982; P-95-96

Table

2. Health Information of India; 1986, p. 141-142

3. Health Information of India, 1989.

10.19 gives the percentage distribution

576,655

of

hospitals and the number of beds therein for the years 1979,

1983, 1987 and the distribution for the 2001. Table 10.19

also provides the average number of beds in hospitals of

different sizes.

308

Table ~.10.19

Percentage distribution of hospitals and Beds and the average size of hospitals in bed capacity size grOJp for ttw years 1979,

1983, 1987 and 2(X)1

Bed- /. age distribu- % age distribu- Beds per hospitals size hon of Hospitals hal of Beds capa- '. * .. City 1979 1Q83 1987 2001 1979 1983 1987 2001 1981 1983 1987 2001 group

1. 2. 3. 4. 5. 6. 7. 8. 9. 10 •. 11. 12. 13.

-< 25 48.8 53.6 59.9 66.83 8.0 9.2 11.4 15.0 12 12 11 11

25 - 50 21.7 20.6 18.7 15.90 10.6 11.1 11.5 12.0 38 3JT 37 37

51 - 75 6.4 5.5 4.8 3.95 5.2 5.0 5.0 5.0 63 62 62 62

76 -100 5.6 5.1 4.2 3.48 6.7 6.7 6.5 6.6 92 91 93 93

101-200 9.0 7.6 6.3 5.00 16.8 16.2 15.6 1~~.0 149 147 147 147

201-300 3.4 3.1 2.5 ' 2.06 10.8 11.1 10.9 10.9 252 249 262 262

301-400 1.4 1.3 1.1 0.89 6.4 6.6 6.4 6.4 350 347 351 351

401-500 0.9 0.7 0.6 0.49 5.5 4.5 4.6 4.6 462 454 466 466

501-600 0.6 0.5 0.4 0.$ 4.3 4.1 4.4 4.4 558 546 601 601

600-700 0.6 0.5 0.4 0.30 5.3 4.6 4.5 651 653 653 653 20.0

700 + 1.5 1.4 1.1 0.74 20.3 20.9 1.9.2 10)9 .t027 1056 1056

Total 99.9 99.9 100.0 100.0 99.9 100.0 100.0 99.9 70 69 60 52 All India

* Fixed on the basis of trends.

309

3. Estimating tbe number of hospitals by beds oapacjtv for

The number of beds are, thereafter converted into number

of hospitals by dividing them with the average bed size.

The average bed size of the hospitals as observed during the

year -1987 has been assumed to be valid for the year 2001

also. Applying the average bed size to the number of beds

in each hospital size group the number of hospitals have

been obtained and are given in Table to.20.

Table 80.10.20

Estimated number of hospitals by bed capacity 2001.

Average Number GHuls Average bed- Number of Percentage hospitals in 2001 size estimated distribution bed size hospitals

(Col. 2) & (Col. 3)

l. 2. 3. 4. 5.

< 25 116,670 11 10,606 66.83

26 - 50 93,335 37 2,523 15.90

51 - 75 38,890 62 627 3.95

76 - 100 51,334 93 552 3.48

101 - 200 116,669 147 794 5.00

201 - 300 85,557 262 327 2.06

301 - 400 49,779 351 142 0.89

401 - SOD 35,778 466 77 0.49

501 - 600 34,223 601 57 0.36

601 - 700 31,112 653 48 0.30

701 + 124,448 1056 118 0.74

Total 777,795 52 15,871 100.00

310

4. Estimating the state~ise number of hospitals in 2001

. App~Mi.'\:x -Table J: provides the number of hospitals in

different states with different bed-size capacity for the

year 1987. The same distribution has been used to distrib-

ute the estimated number of hospitals (shown in

~ \0.20), to get the statewise number of hospita~s of dif­

ferent sizes. The number so estimated by States is shown in

Appendix Table II.

5. Estimating the number of requirement for nurses

for Administration in 2001.

The statement below provides the recommended posts of

Superintendent/Deputy Superintendent/Assistant Superintend­

ent/Matron/Assistant Hatron etc., for different sizes of

hospitals:-

Size of Hospital

50 Bedded

100 Bedded

200 Bedded

300 Bedded

500 Bedded

600 Bedded

750 +

Recommended 'number of Posts

One Assistant Matron

One Matron

One Matron

One Hatron, One Asstt. Matron

One Matron, Two Asstt. Hatron

One Matron, Two Asst. Matron

One Superintendent, One Deputy super­

intendent & 10 Assistant superin~

tendent

311

Applying these norms to the estimated number of hospi-

tals in each ~ize and for each state, the requirement of

nurses for Administration have been estimated. These are

shown in Table 10.21.

Table 10.21

Requirellents of nurses by category for administration in 2001

'By CategorY Asstt./Asstt. Total States Suptt. DY.Suptt./Matron Suptt:/tiatron

1. Andhra Pradesh 7 110 158 275

2. Assam 3 33 70 106

3. Bihar 8 78 145 231

4. Gujarat 5 89 171 265

5. Haryana 1 18 38 57

6. Himachal Pradesh 22 27 49

7. Jammu & Kashmir 13 17 30

8. Karnataka 10 95 191 296

9. Kerala 9 190 317 516

10. Madhya Pradesh 5 66 98 169

11.Maharashtra 21 192 395 608

12. Orissa 3 29 75 107

13. Punjab 3 27 1~ '\O~

14. Rajasthan 3 60 S3 ~'46

15. Tamil .Nadu 10 132 254 396

16. Uttar Pradesh 8 147 260 415

17. West Bengal 12 182 236 430

18. Other States & 10 80 181 271 Union Territories

19. All India 118 1563 2788 4469

312

Teaching

As regards requirements of general nurses as teachers,

complete data on number of teaching posts, the number of

teachers actually working and the proportion of general

nurses holding them are not readily available. In the

present exercise, an attempt is made to work out "the re­

quirement of nursing for 'teaching' on normative ~asis i.e.

by using teacher-pupil ratio recommended by Indian Nursing

Council.

For this, first we have estimated the level of admis­

sion in the year 2001. Actual data on admission are avail­

able upto 1982 and then for the year 1986 and the data on

outturns are available upto the latest year. Relating the

past data on admissions upto 1982 with the corresponding

outturns, the "admission level of the yea~ 2001 is estimated

to be 40,000. For obtaining these admission level" for

different states, the pattern of admission observed in the

year 19~6 has been assumed to be valid for the year 2001.

And the requirements of teachers in terms of total

teaching posts are, thereafter jerived by applying the

teacher pupil ratio 1 : 10, which is obtained on the basis

of the norm prescribed by INC. But to ascertain the propor­

tion of these estimated teaching posts as to how many will

be occupied by gen~ral nurses, an analysis of the data

col~ecte~ for the 92 training schools for nursing for the

year 1989 from the INC record has been made.

313

The INC invites large data from the training schools on

different aspects through prescribed formats.' It is noted

through discussion, a significant p~G~Ttw~ of the institu­

tions either do n6t respond or send incomplete information.

However, the formats from 92 institutions were found to be

fairly complete in respect of the important items of infor-

mation like number of students under training, teaching

faculty by qualification etc.

A distribution of the teaching staff employed in these

. 92 institutions classified by post, qualification and the

management of the institution brought out the proportion of . .

GNs occupying teaching posts works out ~o be only 31.6%.

This has . been applied to the estimated requirements of

teaching post to get the number of posts which will be

occupied by GNs in 2001. The number works out to be 1265

only.

Statewise requirement of teachers so worked out are

shown in Table 10.22.

Table follows ..... .

'.

314

Table 10.22

Estimated requirements for teaching faculty in -nursing school and tha~ tor general nurses in 2001

States

1

Distribution Pattern ot '~86 adllission

2

Envisaged Admission in 2001

3

Require.ents of Teachers Total GSs

4 5 --------------------------------------------------------------1. Andhra Pradesh

2. Assam

3. Bihar

4. Gujarat

5. Haryana

6. Himachal Pradesh

7. Jammu & Ka~hmir

5.38

2.15

6.08

2.19

1. 73

0.86

8. Karnataka 6.85

9. Kerala 11.54

10.Madhya Pradesh 4.53

11.Maharashtra 17.38

12. Orissa 1.89

13. Punjab 2.00

14. Rajasthan 5.63

15. Tamil Nadu 9.88

16. Uttar Pradesh 6.44

17. West Bengal 6.72

18. Other States & 8.75 Union Territories

19. All India 100.00

2,152

860

2,432

876

692

344

2,740

4,616

1,812

6,952

756

800

2,252

3,952

2,578

2,688

3,500

4 0,000

315

215

86

243

88

69

34

274

462

181

695

76

80

225

395

258

269

350

4,000

68

27

77

28

22.

11

87

146

57

220

24

25

71

125

82

85

110

1,265 .

IV. COHHUHITY SBRVICES

Steps involved in working out the requirements of nurses

for community services are:-

(i) Estimating the 'infrastructure' viz., CHCs, PRCs

and Sub-Centres in the year 2001 on the basis of

the population norms.

(ii) Determining the respective population of plain &

difficult areas because the norms of the two areas

are different.

(iii) Estimating the requirement of nurses by .applyina

appropriate staffing pattern norm.

Methodological,details of each of the ~bove eteps are as

follows:-

1. Estjmatjng the Infrastructure

According to the national norms, there will be one S~b­

Centre for every 5000 population in plain areas and that for

3000 population in difficult and hilly, te~~~\n; one PHCs

for 30,000 population in plain areas and that for 20,000 in

difficult i.e. hilly, tribal and desert areas; and one

community health centre will be provided for a population

between 80,000 to 1.20 lakhs to serve as a referral unit for

4 PHCs.

Before working out the number of these different insti­

tutions, it becomes essential, first, to determine the

difficult areas .in each state and the population inhibiting

therein. The progortion of population residing in difficult

318

areas in each state in 2001 are presented in Appendix Table

III. Based on the respective population figures of plain

and difficult areas, that the 'infrastructure' is estimated

by applying the above norms. The infrastructure so worked

out is presented in Appendix Table IV.

II. Estimating the Respective Population in Difficult Areas

The Expert Committee on Heal(h Manpower (1987) has

assumed" 10% of the total rural population as population

residing in difficult areas; but the basis for this assump­

tion is not provided. In the present exercise, we have

attempted to estimate the population residing in difficult

areas by considering two indicators i.e. (i) the percentage

of tribal population to total rural population and (ii)

dispersion of the population ~easured in terms of the densi­

ty of a given state as percentage of the all India density.

It is assumed that special services are required in either

of the two situations. Therefore, in respect of each state,

the weightage of one of these indicators which is greater,

has been taken as the proportion of difficult area and the

same is applied to the projected population of each state in

the year 2001, the population living in difficult areas has

been thus obtained; the remainder being treated as living in

plain areas. With this process the population residing in

difficult areas works out to be 18.10% in 2001, as against

the 10% assumed in the Report of the Expert Committee. The

relev~nt data are provided in Appendix Table III.

317

III. Bstjmating the-regujrements of Hurses

The approved national norms seek the provision of one

nurse/mid-wife per PHC and 7 nurses/midwives per CHCs. The

High . Power Committee on Nurs"" & Nurs ing

estimated the requirements of nurses for

Profession have

community health

services assuming one PHN and one Nurse midwife per PHC and

one PHN officer and 7 nurses midwives in a CHC.

In the present exercise, we have adopted the national

norms to work out the requirements of nurses as there were

only 16,448 nurses working in rural areas out of the total

labour force stock of nurses 169,977 in 1991. This provided

ju?t less than· one nurse in a PHC; (the number of PHCs

functioning in 1991 were 22,065) and leaves none for CHCs.

Therefore, to plan for one PHN and one Nurse midwife per PHC

and one PHN of~icer with seven nurse midwives appear to be

somewhat too high.

The requireme~ts have worked out by applying the na-

tional norm i.e. one nJrse midwife per PHe and seven nurse

midwife per CHC and the estimates are provided in Table

10.23.

Table follows .....

318

bble 10,23

Estimated Requirement of Hurses for CoulUnity Health Seryi'ces in 2001

States Requirenent of Nurses in 2001 for CHCs PACs Total

1 2 3 4 ------------------------------------------------------------1. Andhra Pradesh 3,535 1, 723 5,258·

2. Assam 1,897 929 2,826

3. Bihar 6,111 2,991 9,102

4. Gujarat 2,128 1,067 3,195

5. Haryana 826 395 1,221

6. Himachal Pradesh 462 264 726

7. Jammu & Kashmir 567 323 890

8. Karnataka 2,212 1,109 3,321.

9. Kerala 1, 771 844 2,615

10. Madhya Pradesh 3,927 2,058 5,985

11.Haharashtra 3,486 1,698 5,184

12. Orissa 2,072 1,042 3,114

13. Punjab 817 437 1,354

H,. Rajasthan 3,024 1,606 4,630

15. Tamil Nadu 2,709 1,294 4,003

16. Uttar Pradesh 7,95::: 3,828 11,780

17. West Bengal 3,871 1,944 5,815

18. Other States & 840 442 1,282 Union Territories

19. All India 48,307 23,994 72,301

319

II. AUXILIARY NURSE KIDWIFB/LAOY HBALTH VISITOR

The requirements for ANHs have been worked out through

a combination of techniques comprising of the programmatic

approach, the population ratio and the staffing pattern

norms. It may be mentioned here that the services of ANMs

are an important component of the rural health care delivery

system wherein the services are provided through an infra­

structure consisting of CHC/PHC and Sub-centre which are

supposed to provide the preventive, promotive and curative

services in an integrated manner. The ANMs are employed in

the sub-centres.

1. Outline of the Present Strategy for Rural Health Care

Services

As per the present strategy, a sub-centre is meant to

cover a population of 5000 in plain rural districts and a

population of 3000 in rural-hilly, tribal and other diffi­

cult (desert) are?s and is the first primary contact health

institution at the grass root levels. A sub-centre has

staff of a HW(F)/ANM and HW(M) and as such this becomes a

crucial category responsible for implementation of several

health programmes and for the various services required to

be provided under these programmes.

A primary health centre is' provided for every 30,000

population in pl~in r~ral areas and 20,000 population in

tribal/hilly and backward areas .. The complement of staff to

be provided in a PHC consist~ of one medical officer, one

320

community health officer, one pharmacist, one nurse midwi~e

and HW(F), one health educator, one HA(F) and one HA(M),

lab-technician and other office staff. One PHC is supposed

to cover Six Sub-Centres. It means that the HA(F) is re-

quired to supervise tbe work of six HWs(F).

A eHe is designed as a referral institution for four

PHes under it and is complemented with 4 medical officers

specially trained to function as physician trained in public

health, obstet'lician, pediatrician, Surgeon., seven nurse

midwives, one pharmacist, one lab-technician, one radiogra-

pher, two ward boys and other class IV staff.

It is thus evident that ANMs are employed in Sub-Centres

and PHes; one in each sub-centre and one in each PHC, 'and

there is one post'of HA(F) to supervise Six ANMs posted in 6

sub-centres under a PHC.

2. Methodology in the Present Bxercise

Steps involved in estimation of the requirements of

ANMs/LHVs are:-

Estimating the infrastructure with the help of

the population norms provided under present

strategy;

(ii) Deriving the estimates of requirement . of

ANMs/LHVs/PHNs as per the norms specified under

two alternatives.

The methodological details of each of these steps 6~

discussed below:-

321

(i) Estimation of Infrastructure for the year 2001

Table 10.24 provides the number of CHCs, PHCs and Sub-

centres in the year 1971, 1981, 1991 and for 2001.

Table lO.24

Growth of Infrastructure. 1971-2001 ------------------~-----~--------~-------------------------

Number of Institutions Year CHCs PHes Sub-Centres

1971 5,112 27.929

1981 5,740 51, 184

1991 1,932 22,065 130,983

20G-1Ot 6,901 23,994 147,936

(j., Appendix Table IV.

The number of these institutions for the year 2001 have

been estimated by applying the national' norms to the

projected population dwelling in plain and difficult rural

areas.

The statewiseestimated number of CHCs,PHCs and subcen~

tres for the year 2001 are presented in Appendix Table IV.

(ii) Deriving the Requirements of ANKs/LHVs/PHBs in 2001

In the p~esent exercise we have attempted to estimate

requirement of ANMs/LHVs under two alternative assump-

tions viz.,

322

Alternative I: Based on the existing staffing pattern nora

One ANH

One ANti

One LHV

for One Sub-Centre

for One PHC

for One PHG:

Alte"rnative II Staffing Pattern as suggested by High

Power Committee

2 ANMs

1 LHV

for Dne Sub-Ceritre

For three ANMs

The estimates worked out under the two alternatives are

shown in Table 10.25 and 10.26. It will be seen from the

Tables that the requirements under alternative II are about

double the requirements under I.

In the subsequent Chapter, an attempt is mad~-~o compare

these different s~ts of requirements for nurses/ANMs and

LHVs in the year 2001 with the probable supply at that point

of time to brifl3 out the likely manpower situation and spell

out various policy issues emanating from the discussion

thereon.

Table follows ••••.

323

Alternative I

states

1

1. Andhra Pradesh

2. Assam

3. Bihar

4. Gujarat

5. Haryana

6. Himacha( Pradesh

7. Jammu & Kashmir

8. Karnataka

9. Kerala

10.Madhya Pradesh

11.Maharashtra

12. Orissa

13. Punjab

14. Rajasthan

15. Tamil Nadu

16. Uttar Pradesh

17. West Bengal

18. Other States & Union Territories

19. All India

Table 10.25

Requirements of ANMs • LHVs in 2Q01

Requirements in 2001 for

ANMs LHVs Total

2 3 4

12,217 1,723 13,940

6,595 929 7,524

21,268 2,991 24,259

7,686 1,067 8,753

2,762 395 . 3,157

2,027 264 2,291

323 2,799

7,975 1,109 9,084

5,912 644 6,756

15,153 2,058 17,211

12,050 1,698 13,748

7,520 1,042 8,562

3,061 437 3,498

11,906 1,606 13,512

9,066 1,294. 10,360

26,948 3,828 30,776

14,036 1,944 1~,980

3,272 442 -:,,714·

171,930 23,994 195,924

324

Table 10.26

Alternative II - Requirements for ANHs, LHVs & PHN in 2001

states

1

1. Andhra Pradesh

2. Assam

3. Bihar

4. Gujarat

5. Haryana

6. Himachal Pradesh

7. Jammu & Kashmir

8. Karnataka

9. Kerala

10.Madhya Pradesh

11.Maharashtra

12. Orissa

13. Punjab

14. Rajasthan

15. Tamil Nadu

16. Uttar Pradesh

17. West Bengal

18. Other States & Union Territories

19. All India

Requirements for 2001

ANMs LHVs TOTAL

2 3 4

20,988 6,996 27,984

11,332 3,777 15,109

36,554 12,185 48,739

13,238 4,413 17,651

4,734 1,578 6,312

. 3,526 1,175 4,701

4,306 1,435 5,741

13,732 4,577 18,309

10,136 3,379 13,515

26,190 8,730 34,920

20,704 6,901 27,605

12,956 4,319 17,275

5,248 1,749 6,997

20,600 6,867 27,467

15,544 5,181 20,725

~6,240 15,413 61,653

24,184 8,061 32.245

5,660. 1,887 7,547

295,872· 98,623 394,495

325

Requirements for PHN upto

PHCs level

5

-1,723

929

2,991

1,067

395

264

323

1,109

844

2,059

1,698

1,042

437

1,606

1,294

3,828

1,'144

442

23,994

Appendix Table I

Hospitals by bed size in 1987

----------------------------------------------------------------States 51- 76- 101- 201- 301- 401- 501- 601- 701

75 100 200 300 400 500 600 700 + ---------------------------------------------------------------

1 2 3 4 5· 6 7 8 9 10 ---------------------------------------------------------------1- Andhra Pradesh 28 18 44 18 9 3 2 2 6

2. Assam 14 12 12 7 1 1 1 0 3

3. Bihar 19 17 29 15 3 3 2 1 7

4. Gujarat 48 29 44 1': 4 3 2 1 4

5. Haryana 7 11 8 2 1 2 1

6. Himachal Pradesh 13 6 13 2 1

7. Jammu & Kashmir 0 82 6 1 2 1

8. Karnataka 19 22 26 18 9 4 1 6 9

9. Kerala 95 48 88 30 9 4 2 5 8

10.Madhya Pradesh 11 12 36 1 4 3 :;2 1 4

11.Maharashtra 38 44 60 30 16 5 11 5 8

12. Orissa 23 9 14 5 1 3

13. Punjab 7 19 11 4 2 1 1 3

14. Rajasthan 12 16 22 11 5 3 2 3

15. Tamil Nadu 37 33 44 17 12 7 6 7 9

16. Uttar Pradesh 58 56 77 13 8 4 4 7

17. West Bengal 22 24 57 42 14 6 7 3 11

18. Other States & 15 23 20 15 7 6· 4- 1 9 Union Territories

19. All India 466 407 611 240 105 57 42 40 108

326

Appendix Table II

Statewise Numbe .... of Hospitals by bed-$ize in 2001

-----------------------------------------------------------------, States 51- 76- 101- 201- 301- 401- 501- bOl- 701

75 '100 200 300 400 500 600 700 +

-----------------------------------------------------------------1 2 3 4 5 6 9 8 9 10

-----------------------------------------------------------------1. Andhra Pradesh 38 24 57 2S 12 4 3 2 7

2. Assam 19 16 16 10 1 2 1 0 3

3~ Bihar 26 23 38 20 4 4 3 1 8

4. Guja .... at 65 39 57 14 ~ 4 3 1 5

5. Haryana 9 15 10 3 1 3 1

6. Himachal Pradesh 17 9 17 3 2

7. Jammu & Kashmir 0 11 8 1 3 -2

8. Karnataka 26 30 34 25 12 :5 1 8 10

9. Kerala 127 65 114 41 12 5 3 6 9

10.Madhya Pradesh 15 16 47 1 5 4 3 1 1

11.Maharashtra 51 60 78 41 23 7 16 6 21

12. Orissa 31 12 18 7 1 3

13. Punjab 9 26 14 5 3 1 1 3

14. Rajasthan 16 22 29 15 7 4 2 3

15. Tamil Nadu 50 45 57 23 16 9 8 9 10

16. Uttar Pradesh 78 76 100 18 11 5 5 8

17. West Bengal 30 33 74 56 19 8 9 4 12

18. Other States & 20 - 31 26 20 10 8 5 1 10 Union Territories

19. All India 627 552 794 327 142 77 57 48 118 ----------------------------------------------------------------

327

Appendix Table III

PcpulatiCJ"\ in Diff'f4\.tt- A-cea.8. ~.~

Per-centage of Populatic:n in' :::lOs +p.

3tates Tribal Density Difficult Rural Difficult Total to rural based one Areas cnes . Rural

1. 2. 3. 4. 5. 6. 7.

L ?lndhra Pradesh 5.92 9.64 9.64 445,515 47,530. 493,045

2. Assam 10.93 10.73 236,Ci33 28,371 264,404

3. Bihar 11.f::A) 11'f::A) 749,831 98,394 . 848,22!l

4 •. 9..\jarat 22.81 21.35 22.81 221,752 65,5z:t 287,281

5. Haryana 118,372 118,372

6. Himachal Pradesh 4.24 All Hilly 100.00 52,887 '52,887

7. Jamru & Kastmir All Hilly 100.00 64,002 .64,602.

8. Kamataka 21.40 12.36 21.40 236,165 64.299 300,464

9. Kerala 0.68 0.68 250,531 1,715 252,246

10.Madhya Pradesh 31.42 44.19 44.19 282,239 223,498 505,737

11.Maharashtra 9.90 4.12 9.90 437,483 48,070 485,553

12. Orissa 24.19 24.34 24.34 210,831 67,825 278,656

13. Punjab 131,179 131,179

14. Rajasthan 12.81 52.06 52.06 183,278 199,030 382,308

15. Tamil Nadu 0.70 0.70 384,097 2,708 368,805

16. Uttcir Pradesh 4.19 4.19 10,77,466 47,120 11,24,586

17. West Bengal 24.91 24.91 389,3'Z7 129,154 518,431

18. Other States & 5:>.45 50.45 52,467 53,420 105,837 Union Ter\itor,es

19. All India 54,06,~ 11,94,152 66,00,718 (81.91 ) (18.09)

328

Appendix Table IV Estilated HUlber at CHes • PHCs in 2001

States No. of CHes No. of PHCs SuD-centres Difficult Plain Total Difficult Plain Total Oi f1icul t Plain Tot~l

Areas Areas Areas -Areas

2 T ~ c 6 7 8 !(I .' .'

L A.ndflra Pradesh ~9 446 505 238 1485 1729 1584 8910 10494

'j Assam Tr 236 271 142 797 92~ 946 4710 1:;'; ... .:. ... t "'000

'1 Bihar 121 ?50 B73 4Q'j 2499 2991 3280 4435 Em?· .....

4. 6ujarat B2 222 304 329 73'1 1(169 2184 4435 ~WI

~ Haryana 118 118 395 395 2367. 2367

~. Hitacha! Pradesh 66 ·~6 . 264 2M 1763 1763

"7 Jaillu &: tasilAir al 91 323 3'i~ 2153 1153 "'v

a. t.arnatata 80 236 316 322 7a7 11M 2143 4723 b866

tl ~erala 2 251 25J 9 835 944 57 5(111 S068 .'.

10.;taahya Pradesh 279 2S2 561 1117 941 2(158 7450 5645 13095

11 Jliiharas!ltra 60 438 493 240 1458 1698 16(12 8750 1(!352

P Orissa a5 211 296 339 703 1042 2261 4217 6478

13. Punjab 131 131 437 437 2624 2624

14. RaJ 3::: than 249 183 432 ~95 611 16(16 6634 36bb 10300

15. Talil Nadu 3 384 387 14 1280 1194 90 7682 7772

16. Uttar Pradesh 59 1077 1i36 236 3592 3818 1571 21549 23120

17. Hfs t Sl!nga 1 164 389 ~53 120 267 175 4306 7787 12092

18. Othl!r states & 67 53 110 267 175 442 1781 1049 2830 Union Territoril!s

19. All India 1494 54tH 6901 5972 18022 23994 39804 108132 147936

329