Are we measuring our health workforce shortage right?
The article is authored by Siddhesh Zadey, co-founding director, ASAR & commission fellow, Lancet, Yash Kamath, and Shavari Mande, final year MBBS students at Seth GS Medical College, Mumbai. Mande is also a researcher at ASAR.
If one were to think of a public health facility in India, they would imagine long queues of patients lining up for scarce outpatient care, doctors and nurses buzzing around to handle the massive patient list, and security trying hard to keep people in check. To overcome staff shortages, most policies rely on population-level thresholds, such as the popular one doctor per 1000 people. However, such thresholds leave a lot out when we think of health care facilities as systems. Such thresholds don’t account for differences across health facility setups, working hours and workload pressures on health workers, among other things. There is a need to monitor workforce shortages and workload pressure on health workers at a more granular level to improve the overall productivity. The Workload Indicators of Staffing Need (WISN) is a human resources for health (HRH) management method supported by the World Health Organization (WHO) to quantify shortages and workload using data on time taken for various clinical and supporting (administrative and other) tasks and resources available. WISN considers annual available working time, actual work, and standard time required for each activity.
The first WISN implementation was published by WHO in 1998 and it was improved upon in 2010 by developing a user-friendly software that is now used by representatives from over 140 countries. In practical terms, WISN uses a data-driven approach to inform how many more (or less) health workers are needed for running an optimised healthcare system where no staff are overworked or underutilised. Countries such as South Africa, Namibia, Bangladesh and others have successfully used WISN to revise their staffing norms for adequate supply and equitable distribution of personnel among available facilities and even development of new HRH cadres. Previously, small scale WISN-based assessments have been conducted in India, focused mainly on nurses working in different medical specialties and medical officers working at primary health care centres (PHCs) showing a shortage of these cadres in PHCs. Some studies have pointed to tertiary care hospitals having a surplus of staff. However, the smaller samples and narrow focus of past studies make it difficult to use the date for national HRH planning.
A recent analysis giving nationally representative estimates has provided some insights about how WISN can be used for HRH policy making and planning. The study used existing survey data from 93 facilities from five states over eight years to create WISN calculations for various HRH cadres at rural public primary and community health care centres (PHCs and CHCs). Results showed an overall shortage of all cadres at PHCs and CHCs. Only seven states had an adequate number of PHC doctors. Workload pressure was found to be very high among nurses at PHCs and CHCs with the exception of a few states, and was very high among the specialist doctors at CHCs across the country. PHC doctors and CHC general duty medical officers (GDMOs) showed mild workload pressure. Workload pressure on doctors at PHCs was associated with that on nurses, showing that such PHCs can be particularly vulnerable to overworking.
Public health care centres staff HRH as per the Indian Public Health Standards (IPHS) norms based on population density in a particular area. Doctors at PHCs and GDMOs at CHCs were just enough as per IPHS norms, while nurses, at both PHC and CHC levels were drastically understaffed, with deficits ranging from 15 at PHCs to upto 40 nurses per centre for CHCs in some states. Specialist doctors had a staffing deficit of 1-2 per centre in CHCs. Overall, there is a large disparity between the workforce requirements suggested by WISN and the actual number of sanctioned HRH by the government. These findings point towards the need for revised sanctioning norms for HRH in rural India.
Unlike WISN, current IPHS guidelines define Centre-contingent norms for HRH sanctioning that do not account for workload pressure on HRH cadres and differences in healthcare demands leading to under-sanctioning across several states, particularly for nurses and specialist doctors. There is an urgent need for National Rural Health Mission’s programmatic scale-up, using the WISN approach, for HRH to meet rural India’s health demands.
The article has been authored by Yash Kamath & Shavari Mande, students of Seth GS Medical College, Mumbai. Shavari is also a researcher at ASAR, Pune & Siddhesh Zadey, co-founding director, ASAR & commission fellow, Lancet Citizens’ Commission for Reimagining Health System.