Health workforce in India: Why, where and how to invest?
The High-Level Commission on Health Employment and Economic Growth emphasised multiple returns of investment in the human resource for health (HRH). Investments made in HRH not only strengthen the health system but also generate employment and contribute to economic growth (WHO). In India, such investments in HRH have the potential to enhance employment growth. They also increase the share of formal employment instead of informal employment and increase women labour force participation in addition to increase in accessibility to health workers by population, particularly those living in rural and remote areas.
Existing studies highlight acute shortage of health workers at all levels, which has also been reected during the current pandemic crisis of Covid-19. A recent 2020 WHO mid-term review of progress on decade for health workforce strengthening in South East Asia Region 2015-2024, mentions that India needs at least 1.8 million doctors, nurses and midwives to achieve the minimum threshold of 44.5 professional health workers per 10 000 population. India needs to invest in HRH for increasing the number of active health workforce and to improve the skill-mix ratio (nurses-doctors and allied-medical personnel).
This study presents an updated estimate on the size and composition of stock of health professionals and active health workforce in the country. Using the information available from the National Health Workforce Account (NHWA) on the stock of health professionals and Periodic Labour Force Survey (PLFS) conducted by the National Sample Survey Ofce (NSSO 2017–18) on active health workforce, the study estimated a total stock of 5.7 million health workers which included allopathic doctors (1.1 million), dentists (0.27 million), nurses (2.3 million), pharmacists (1.2 million) and traditional medical practitioners (AYUSH 0.79 million). However, the active health workforce size is estimated (from the NSSO 2017-18) to be much lower (3.04 million) with allopathic doctors and nurses estimated as 0.78 million and 1.36 million respectively.
The prime reasons for differences between the two include outmigration of health professionals, economically inactive health professionals and lack of regular updates of NHWA database. Thus for real and accurate estimation, the two data sets that are available must be triangulated for a real and clear idea about the health workforce.
The study highlighted that while many inadequately qualied health workers report themselves as health workers, a large proportion of adequately qualied health workers holding a degree/diploma in medicine are not currently working in labour markets.
Density of health workforce is compared in terms of number of different types of health workforce per 10,000 persons and is an important indicator of availability and accessibility of HRH. The NHWA data, in general reects higher density as compared with the NSSO-based estimates for almost all the categories of health workforce as it provides information on stock data. However, NSSO-based estimates provide information on the active health workforce in the Indian health system. At the all-India level, stock density of doctor and nurses/midwives is 8.3 and 17.4 respectively per 10,000 persons. If the total stock of dentists and traditional medicine practitioners is added, a total stock density in the country would be estimated as 33.7 per 10,000 persons. However, active health workers’ density (as estimated from NSSO) of doctor and nurses-midwives (without adjusting for adequate qualication) is estimated to be 5.9 and 10.3 respectively. The numbers further drop to 4.8 and 5.7 respectively after adjusting for adequate qualications. If all kinds of health professionals are considered (including dentists, traditional medicine practitioners and allied health workforce), the total worker density per 10,000 persons is estimated to be 27.1 without adjusting for qualications and 17.2 after adjusting for qualications.
Among the states, Kerala reported the highest density of doctor workforce (20.96) whereas Delhi had the highest density of nurses and midwives. Considering doctor and nurse workforce together, Kerala, Delhi and Tamil Nadu are on top while Bihar, Jharkhand and Odisha appear at the bottom.
An improved service delivery requires the right skill-mix of these workers (WHO). The High-Level Commission on Health Employment and Economic Growth (WHO 2016b) notes that “optimising the skill-mix by reorganising scopes of practice can improve access to services and reduce waiting time, producing a high patient satisfaction rate”.
The right balance in the skill-mix ratio for health workers provides optimum health-care conditions. Contrasting the skill-mix ratio with the density of doctors at state levels, an inefcient skill-mix is found to exist between doctor and nurse and doctor and allied health professional in most states in India.
For instance, in Bihar and Uttar Pradesh, the density of doctors and nurse-doctor ratio are both very low. In Karnataka and Jharkhand nurse-doctor ratio is slightly better as compared to that in Bihar and Uttar Pradesh even though the density of doctors remains very low. In all these states along with maintaining high skill-mix, there is need to improve the availability of doctors. Similarly, in Madhya Pradesh and West Bengal, the density of doctors is fairly high but the nurse-doctor ratio is low. In these two states, improving the nurse-doctor ratio will lead to a better skill-mix situation. There are also states at the extreme end, i.e. very high doctor density but very low nurse-doctor ratio (Kerala, Jammu & Kashmir) and very high nurse-doctor ratio but very low density of doctors (Punjab, Himachal Pradesh, Chhattisgarh and Uttarakhand).
Size of traditional medicine practitioners (AYUSH) in India is quite sizeable. Total number of active AYUSH practitioners is almost 60-70% of the total number of active allopathic doctors (NHWA 2018; NSSO 2017–18). However, the number of nurses per doctor is less than two. This number is even lower and closer to one if BSc nursing qualications are considered. In most Organisation for Economic Cooperation and Development (OECD) countries, there are 3-4 nurses per doctor (OECD 2019). Although total stock of nurses in the country is approximately three times the number of doctors, a large proportion of nurses are not active in the labour market. The labour force based estimate (NSSO 2017–18) of doctors to nurse ratio is barely 1:1.3. A few states such as Delhi, Punjab, Himachal Pradesh, and Chhattisgarh have a high nurse-doctor ratio but in these states the density of doctor per 10 000 persons is extremely low. There is need to balance densities of doctors and nurses, both for better availability of health professionals and skill-mix. Similarly, the doctor and allied health professionals’ ratio is also very poor which needs attention.
As far as public-private division of health workforce is concerned, bulk of the doctors’ employment remains in the private sector while nurses are almost equally distributed across the public and private sector. Public sector seems to be the sole employer of traditional medical practitioners. This lopsided distribution of health workers not only creates a shortage of trained health workforce in many states and rural areas but also leads to an unequal skill-mix across different types of health workers in different settings.
The public sector is challenged by a high rate of vacancy of sanctioned positions. The Rural Health Statistics highlights this issue. While the shortage is most pronounced for specialists posted at Community Health Centres (CHC), India faces shortages across states for various positions. A review of the serially published reports of the Rural Health Statistics shows a slow but denite growth in the number of health providers at the overall country level. The vacancies are attributed to diverse reasons that range from barriers in recruitment, litigations against recruitment processes and premature exits from the system, especially in contractual positions.
Increase in the number of health workforce and the right balance in the skill mix requires a supply of health professionals at an increased rate. The supply side of health professionals is an important parametre in reaching the goals for minimal optimum density of the health workforce. An analysis of the health workforce projections provides the estimated density of skilled health professionals (doctors, nurses and midwives) per 10,000 population. Considering the current rates of growth are sustained, the required density of health workforce will still not be met as the rise in the number of health professionals will be balanced by a rise in the country’s population. At the present level of growth on the supply side, the skill-mix ratio of doctor-nurse is unlikely to alter by 2030. A near 200% growth on the supply side for nurses will improve the doctor-nurse ratio to 1:1.5 by 2030. This will require a further rapid scale-up of nursing programmes.
The High Level Expert Group report for the Planning Commission in 2012 had suggested a ratio of 1:2:1 for doctor-nurse-auxiliary nurse midwife for India. For achieving this target by 2020, simultaneous efforts would be needed on the demand side of the market as well. The roles for nurses and the functions that are performed by them will need closer attention.
India needs to invest in HRH for increasing the number of active health workers and also improve the skill-mix ratio which requires investment in professional colleges and technical education. India needs to encourage qualied health professionals to join labour markets and ensure additional trainings and skill building for those who are already working but are inadequately qualied health workers. In addition to increased availability of and accessibility to quality he
alth workers by population in general, enhanced investment in HRH will lead to strengthening of the health system for dealing with pandemic situations like Covid-19 and any other epidemic/s. It will lead to economic growth, increased women participation in the labour market, formalization of the labour market and overall economic wellbeing.
Important recommendations for the government would be to assure an adequate and adroit workforce that emphasises expansion of the supply side of the health workforce. This must be prioritised across geographical regions with a shortage of health workforce. Since such decient geographies report a shortage of several categories of health workforce, a systematic effort for co-locating multiple teaching institutions such as medicine, nursing and dentistry should be encouraged.
(The study has been authored by Prof Sanjay Zodpey, Dr Anup Karan and Dr Himanshu Negandhi of Public Health Foundation of India in collaboration with World Health Organization)