Health Manpower in India: Critical Review

DR. BHUSHAN KAMBLE MODERATOR: DR.SAUDAN SINGH/DR.SHALINI SAMNLA

Outline Of The Presentation

Introduction Types of health manpower Suggested norms of health manpower Current status of health manpower Shortfall in current health manpower Recommendation of HLEG

HEALTH MANPOWER Health manpower means people who are trained to promote health, to prevent and

cure disease and to rehabilitate the sick. Health manpower includes: Those health workers who are already working in the field of health services. Prospective health workers, i.e., those who are receiving education and training that

will prepare them for employment in the health sector.

Hogarth J. Glossary of health care terminology. Copenhagen, World Health Organization/EURO, 1975.

Evolution of health manpower norms in India Bhore committee 1946 : Each PHC- 40,000 population should have 2 Medical officers, 4 PHNs,

1Nurse, 4 midwives, 4 trained dais, 2 health assistants, 1 pharmacist and 15 other class four employees

Chadha Committee(1963); one laboratory technician per 30,000 population and one health inspector per 20,000 population. 1 basic health worker per 10,000 population and 1 FPHA per 3-4 BHW

Kartar Singh Committee 1974): one male and female health worker each for 3,000 - 3,500 population at the grassroots, i.e. within a distance of less than 5 kilometers.

Indian Public Health Standards (IPHS) (2007, 2012): 1 Sub center: 3000-5000 with 2 health worker( M& F)

1 PHC: 20000- 30000 with 3 medical officer, 1 AYUSH practitioner, and 20 other staff 1 CHC: 80000-100000 with 5 specialist doctors 1 public health manager, 1 dental surgeon, 6 GDMO 1 AYUSH Specialist and 1GDMO AYUSH and 64 other staff

Types of health manpower Doctors(Allopathic and AYUSH) Nurse Pharmacists Lab technicians Radiographer Health assistant (male & female) Health worker(male) ANM ASHA Anganwadi worker Trained Dai Others(health inspectors, health educator, OT assistant, dieticians etc)

Suggested norms for health manpowerCategory of health personnel Norms suggestedDoctor 1 per 1000 populationnurse 1 per 500 populationHealth worker(male & female) 1 per 5000 population in plain area

and 3000 population in tribal/hilly/hard to reach area

Health assistant (male & female) 1 per 30000 population in plain area and 20000 population in tribal/hilly/hard to reach area

Pharmacist 1 per 10000 populationLab technician 1 per 10000 populationAnganwadi worker 1 per 400-800 populationASHA 1 per 1000 populationTrained Dai 1 per village

Source: Govt. of India (2008), Annual report 2007-08,Ministry of health and family welfare, New Delhi

Current status of Health manpower Health man power in some countries

Country Doctors per 10000 population

Nurses/midwives per 10000 population

Health workers (Doctor, nurses/midwives) per 10000 population

India 7 17.1 24.1Germany 38.9 114.9 153.8UK 28.1 88 116.1Qatar 77.4 118.7 196.1Pakistan 8.3 5.7 14Niger 0.2 1.4 1.6Bangladesh 3.2 2.2 5.4China 14.9 16.6 31.5Sri lanka 6.8 16.4 23.2

Source: World Health Statistics 2015.

The country is producing annually, on an average 31, 298 allopathic doctors. India has the largest number of medical colleges in the world, with an annual production of over

30,000 doctors and 18,000 specialists.

The country has 412 medical colleges(212 pvt. + 200 govt.) with total intake capacity of 52175(24995pvt + 27180 govt.)*

India’s average annual output is 100 graduates per medical college

The availability of one doctor per population of 1319 with a nurse/ ANM availability of 2.4 per doctor.

We are still far from the WHO norms of one doctor per 1,000 population and 3 nurses /ANMs per doctor.

World Health Organization endorsed threshold of 23 workers per 10000[WHO]. World Health Statistics 2015. Geneva: WHO; 2015. *source: medical council of india website

Current status of Doctors

Current status of Doctors……contd

There is huge expansion of medical colleges across the country since 1990 to meet the demand of doctorsMost of pvt. Medical college are located in southern states of india.

Yogesh Sabde, Vishal Diwan, Ayesha De Costa, and Vijay K Mahadik. Mapping the rapid expansion of India’s medical education sector: planning for the future. BMC Med Educ2014; 14: 266.

Current status of Doctors……contd

There is steady rise of allopathic doctors since 2008. This production is not equal across the states so leading to unequitable distribution of doctors

Current status of dentists There is a total workforce of 1,54,436 dental practitioners in India at present, which is expected

to swell to 2,25,000 shortly The country has 305 colleges for BDS courses and 224 colleges which conduct MDS courses.

There has been admission of 26,240 in BDS and 5,505 in MDS during 2014-15 WHO recommends, dentist to population ratio of 1:7500. Dentists-to-population ratio of India, which was 1:300,000 in the 1960’s, At present, in rural India

one dentist is serving 2.5 lakhs of people whereas; the overall ratio of dentists to population in India is 1: 10,000

Due to significant geographic imbalance in the distribution of dental colleges, a great variation in the dentist to population ratio in the rural and the urban areas is seen

About 80% of dentists work in major cities in India Very little oral health care services are provided in the rural areas There are about more than one million unqualified dental health-care providers, or 'quacks', in

India. They have long been blamed for misdiagnosing and mistreating.*

*source: dental council of india website & World Health Statistics 2015

Current status of AYUSH doctors The country is producing annually, on an average 13152 Ayurvedic doctors, 1911 Unani

doctors, 410 siddha doctors, 820 Naturopathy doctors and 12808 Homoeopathic doctors There are 260 Ayurvedic colleges 41 Unani colleges, 8 Siddha colleges, 18 Naturopathy

colleges and 18 Homeopathic colleges as on 1st April 2014. As per CBHI report 2014-15, there is 1 AYUSH Doctor per 1684 population The concept of mainstreaming of AYUSH was an idea in the IXth five-year plan(1997-02) & it

was actually implemented in the country by NRHM in 2005. The objective of main-streaming was to provide choice of treatment system to the patients,

Strengthen facility functionally, Strengthen implementation of national health programme. AYUSH facilities had been collocated in 240 district hospitals, 1716 community health centers

and 8938 primary health centers in 2010. As on 31st march 2015, 10237 PHCs are having AYUSH facility.

source: Ministry of AYUSH &National Rural Health Mission, 2005: Framework of Implementation 2005-2012,GOI.

Current status of Nurses and Pharmacists India has 2865 Institutions producing 1,15, 484 General Nurse Midwives annually and 723

colleges for pharmacy with an intake capacity of 43,300 as on 31st December 2014 There is 1 nurse per 482 population and 1 pharmacist per 1865 population. There is availability of 2.4 Nurse/ANM per doctor. It is projected that up to 2022, there will be

availability of 3 Nurse/ANM per Doctor.

No. of institutions and admission capacity in nursing & para-medical courses in India as on 31st December 2014Courses No. of institutions Admission capacity

General Nurse Midwives

2865 115844

Auxiliary Nurse Midwife (ANM)

1853 52479

Pharmacists 723 43300

Source: CBHI: National Health Profile 2015

Current status of health manpower in Railway, ESI and Defence servicesSector Medic

al officer

Specialist

Super specialist

Dentist

ANM nurse pharmacist

Railways

1685 924 26 25 34 4157 1797

ESI 5964 1661 18 32 0 5014 568Defence

5988 NA NA 658 NA 4600 363

Source: National Health Profile 2015

Sector Total no. of Dispensaries

Total no. of Hospital

Total No. Of beds

Railway 613 125 13702ESI 1303 151 19089

Health manpower in Rural areas

Average Rural Population, rural area and radial distance Covered By Health Facility (Based On Census 2011)

Facility population Rural area (Sq. Km)

Radial distance (Km)

Sub-center 5426 20.27 2.54

PHC 32944 123.09 6.26

CHC 154512 577.32 13.55

SHORTFALL IN CURRENT HEALTH MANPOWER

As on 31st March, 2015, there are 153655 Sub Centres, 25308 PHCs & 5396 CHCs functioning in the country.

While the Sub Centres, PHCs and CHCs have increased in number in 2014-15, the current numbers are not sufficient to meet their population norm.

Number of ANMs at Sub Centres and PHCs has increased from 133194 in 2005 to 212185 in 2015 which amounts to an increase of about 59.3%. Percentage

As on 31st March, 2015 the overall shortfall in the posts of HW(F) / ANM at SCs & PHCs was 5.21% of the total requirement,

SHORTFALL IN CURRENT HEALTH MANPOWER…..contd.

Source: Rural Health Statistics 14-15

SHORTFALL IN CURRENT HEALTH MANPOWER…..contd.

Source: Rural Health Statistics 14-15

SHORTFALL IN CURRENT HEALTH MANPOWER

2005 2015Required

In position

Shortfall

Required In position Shortfall

ANM/HW (F) 169262 133194 19311 178963 212185(59.3)

9326

HW(M) 146026 60756 85270 153655 55657 98027Health Assistant (F)/ LHV at PHCs

23236 19773 3463 25308 13372 12448

Health Assistant (M) at PHCs 23236 20086 3150 25308 12646 15513Doctors(Allopathic ) at PHCs 23236 20308 1004 25308 27421(35) 3002Specialists* at CHC 13384 3550 6110 21584 4078 17525Radiographers at CHC 3346 1337 1176 5396 2150 3406Pharmacists at PHCs & CHCs 26582 17708 2858 30704 23131 8321Lab technicians at PHCs & CHCs

26582 12284 7226 30704 17154 13691

Nursing staff at PHCs & CHCs 46658 28930 13352 63080 65039 12953Source: Rural Health Statistics 14-15 (*PHYSICIAN, OB&GY, SURGEON & PEDIATRICIAN)

SHORTFALL IN CURRENT HEALTH MANPOWER…..contd.

Out of 25308 PHCs, 799 are having 4+ doctors, 770 are having 3 doctors, 2041 are without any doctors, 9649 are without lab technicians and 5553 are without pharmacists

6436 PHCs are having lady doctor. Total 10237 PHCs are having AYUSH facility, bihar having maximum ayush facility 1384

SHORTFALL IN CURRENT HEALTH MANPOWER…..contd.

Reasons for shortfall in health manpower Skewed production of health manpower

Uneven Human resource deployment and distribution

Disconnected education and training

Lack of job satisfaction

Professional isolation

Lack of rural experience

The number of allopathic doctors at PHCs has increased from 20308 in 2005 to 27421 in 2015, which is about 35.0% increase.

Shortfall of allopathic doctors in PHCs was 11.9% of the total requirement for existing infrastructure. Number of CHCs has increased by 2050 during the period 2005-2015. In addition to 4078 Specialists, 11822 General Duty Medical Officers (GDMOs) are also available at

CHCs as on 31st March, 2015. There was huge shortfall of surgeons (83.4%), obstetricians & gynaecologists (76.3%), physicians

(83.0%) and paediatricians (82.1%). Overall, there was a shortfall of 81.2% specialists at the CHCs vis-à-vis the requirement for existing

CHCs.

SHORTFALL IN CURRENT HEALTH MANPOWER…..contd.

Overall, there was a shortfall of 81.2% specialists at the CHCs as compared to the requirement for existing CHCsThe shortfall of specialists is significantly high in most of the States.

Source: Rural Health Statistics 14-15

Reasons for shortfall and vacancy Doctors at CHCs Professional isolation, absence of amenities in rural area, lack of rural experience, lack of job

satisfaction and inability to adjust to the rural life. The uneven distribution of professional colleges and schools has led to severe health system

imbalances across the states Lack of filling up of all vacancies regularly in a time bound manner. No Transparent transfer policies and implementation.

Impact of shortfall of health manpower at SC, PHC & CHC: Over 20% of deliveries are outside health facilities in 485 districts. Over 15% of children in 358 districts receive only partial immunization. 62% of PHCs are conducting less than 10 deliveries in a month, 10% of CHCs do not provide 24x7 normal delivery services, only 19% of CHCs offer caesarean section deliveries

Population Norms under ICDS For AWCs in Rural/Urban Projects 400-800population per AWC

Currently 7,076 Projects and 14 lakh AWCs number of operational projects and Anganwadi have been approved.

As per available information, there are 12.93 lakh Anganwadi Workers (AWWs) and 11.65 lakh Anganwadi Helpers (AWHs) in-position/ working in these AWCs as on 31.12.2014.*

There is Short fall of 1.1 lac AWWs India has 907918 ASHA workers in place, out of which 848169 has received

training as on 31st march 2015# Village health guide : 1VHG per village There are 3.23 lakh VHG at present

SHORTFALL IN CURRENT HEALTH MANPOWER…..contd.

 *Minister of Women and Child Development 07-May-2015 #source: National health mission website

Newer initiatives from the Recommendations Of High Level Expert Group Report On Universal Health Coverage(HLEG) For India 1). Provide one additional Community Health Worker (CHW) at the village level and one urban CHW low-income urban populations, for primary healthcare. one additional CHW at the village level (1 per 500 population) & in underserved urban areas for

low income populations (1 per 1,000 population). The new CHW may be a male or female, belonging to the same village/area. The control of communicable and non- communicable diseases may be assigned to the second

CHW with specific job responsibilities that include basic health promotion and prevention activities

CHWs should be de facto members of the (village or urban-equivalent) Health and Sanitation Committee, which will be involved in monitoring of CHW and disburse a monthly fixed payment of Rs.1500 to each CHW.

The performance based monthly compensation of Rs.1500 should be through ANMs in rural areas and their corresponding equivalent in urban areas.

The estimated availability of roughly 19 lakh CHWs by 2022.

2. Mid-level Professional Rural Health Care Practitioner

Each Sub-Health Centre (SHC), covering 3,000 to 5,000 population, should have a mid-level professional Rural Health Care Practitioner, two ANMs and a Male Health Worker. In urban settings, trained and qualified Nurse Practitioners are recommended in lieu of Rural Health Care Practitioners.

HLEG endorses a ‘Bachelor of Rural Health Care’ (BRHC) course with a 3-year curriculum which should have an intensive component covering primary and preventive healthcare

It should be mandated through legislation that a graduate of the BRHC programme is licensed to serve only in specific notified areas in the government health system.

BRHC college exists in all districts with populations of over 5 lakh. These colleges will be co-located with or closely aligned to District Health Knowledge Institute

It is expected that full coverage of BRHCs at the sub centre will be achieved by 2030. Similarly, Nurse Practitioners would be positioned to serve vulnerable urban populations and

supervise urban CHWs. BSc (community health) has been approved by Central govt. on August2014 and Assam govt. has

started this course since june 2015.

3. Increase HRH density to achieve WHO norms of at least 23 health workers (doctors, nurses, and midwives) per 10,000 population as well as 3 nurses/ANMs per doctor (allopathic).

This will be done by increasing financial allocation for strengthening the infra-structure for SC, PHC & CHCs and creating new medical college at each district.

4: Provide adequately skilled ANMs at SHCs, PHCs and CHCs through the addition of Auxiliary Nurse Midwife (ANM) schools in 9 priority states phased from 2012 to 2017.

5: Increase the availability of skilled nurses to achieve a 2:1:1 ratio of nurses to Auxiliary Nurse Midwives, (i.e. minimum of 2 nurses and one ANM) to allopathic doctors, through the provisioning of new nursing schools and colleges.

To fulfill these recommendations Simultaneously progress towards making available at least one ANM school in all districts with over 5 lakh population and Strengthen Lady Health Visitor (LHV) training centres to ensure adequately trained CHW and ANM supervisors

7: Utilize available AYUSH doctors within the state At PHCs, CHCs And District Hospitals.

Optimally utilize available AYUSH doctors will be done in the following ways:

Facilitate the skill up-gradation of AYUSH doctors for the provision of primary healthcare at SHCs through a 3-6 month bridge course.

Create posts of AYUSH doctors at the PHCs, CHCs and district hospitals. This gives patients the option of availing of AYUSH or allopathic services, as per their preference.

Support AYUSH practice through the use of an AYUSH Essential Drugs List. This will enable AYUSH practitioners to use their system-specific knowledge.

Create career trajectories in public health and health management for this cadre.

Training opportunities be ensured for these cadres with opportunities for skill-building, and career advancement

- Plans to set up six AIIMS like institute in J&K, Punjab, Tamil Nadu, Himachal, Assam and Bihar

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Revised.New Delhi: MOHFW, Government of India; 2012. Anand S, Fan V. The Health Workforce in India, 2001: A Report prepared for the Planning Commission,

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