India’s policies should view human resources for health
The article has been authored by Vidhi Wadhwani, second year MBBS student, GCS Medical College, Ahmedabad and researcher at Association for Socially Applicable Research (ASAR) and Siddhesh Zadey, co-founding director, ASAR and Commission Fellow, Lancet Citizens’ Commission for Reimagining Health System.
Universal Health Coverage (UHC) aims to achieve quality health care that is accessible to one and all at any time and place at an affordable cost. While there are several criteria to attain this goal, having an adequate number of human resources for health (HRH) is arguably one of the most important of all. HRH is an umbrella term for all people primarily involved in the enhancement of health, including doctors, nurses, midwives, dentists, pharmacists, etc. India is one of the 57 countries listed as ‘countries suffering from an HRH crisis’ by the World Health Organization (WHO) in its 2006 report. Things have improved only marginally since then.
While one would assume that having an adequate number of HRH personnel might be a satisfactory measure of a country’s progress towards UHC, availability is only one of four dimensions WHO invigorates countries suffering from HRH deficit. They include- availability, accessibility, acceptability, and quality (AAAQ). Going beyond adequate availability, HRH should be easily accessible at all places and times, including the remotest areas. Further, HRH should include a diverse group of people representing the broader population so that they are acceptable to most people. For example, a female patient would be more comfortable seeing a female doctor than a male doctor. Finally, and arguably most importantly, HRH should be skilled in all aspects of their job and should have high quality training so that the quality of care they provide is not compromised.
A recent study has formulated a family of deficit indices to quantify the AAAQ deficiencies to be able to look at them objectively. Theoretically, the deficit indices can be positive, negative, or zero. Taking the example of availability deficit (AvD), when the density of currently present HRH per 10,000 people is equal to the required HRH, there’s no deficit or surplus, hence AvD is zero. A positive AvD depicts a deficit that needs attention while a negative AvD shows surplus. Deficits of the four dimensions signify different things. Availability deficit (AvD) measures the shortage of HRH present compared to required HRH. Accessibility deficit (AsD) measures the maldistribution of HRH in rural areas relative to urban areas. Acceptability deficit (ApD) measures the imbalance of female to male HRH. Quality deficit (QD) measures the shortage of people having a professional licence to practice medicine relative to unqualified personnel (quacks).
Using the data from the last Census in 2011, the study found that in India, nurses, dentists, and pharmacists face availability deficit, whereas auxiliary nurse midwives (ANMs) and AYUSH (alternative medicine) practitioners show a surplus, followed by allopathic doctors, compared to norms set by the high-level commissions. All the above mentioned HRH cadres, except ANMs, showed accessibility deficit. While several cadres have an acceptability deficit, nurses show surplus females and dentists approach a zero deficit. All cadres had a positive quality deficit, with highest QD for pharmacists.
A related study showed that, all deficit indices showed a general decreasing trend from 1981 to 2011, except accessibility deficit. Availability deficit for all cadres decreased, except for pharmacists and AYUSH, both of whom showed about a 75% increase in 2011 compared to 1981. Accessibility deficit values for all cadres were almost constant from 1981 to 2011 with less than 1% change, except for ANMs, who showed an exceptional improvement in accessibility. Acceptability deficits showed small decreases (<15%) for all cadres except dentists (53% decrease) and nurses (72% decrease). Quality deficit showed a decreasing trend for all cadres.
Beyond the numbers, it is important to see if the country’s health policy prioritises AAAQ dimensions. Comparing the number of recommendations concerning the AAAQ dimensions in the 1983, 2002, and 2017 iterations of the National Health Policy of India (NHPI), it is seen that the number of recommendations regarding AAAQ dimensions has increased over time, from only 13 in 1981 to 120 in 2011 denoting growing policy attention. Among dimensions, acceptability has been largely neglected, with no recommendations in 1983 and only 10 out of 120 recommendations in 2011. The NHPI have mostly focused on doctors across three decades, leaving out other HRH cadres. There are also policy mismatches. While looking at accessibility, the 2017 policy provides no relevant recommendations for dentists who face a critical deficit. The recommendations related to quality have a disproportionately high focus on doctors, who suffer from lower quality deficit than pharmacists and nursing cadres.
In absence of a standalone human resources for health policy, the existing National Health Policy needs to take up a multidimensional approach for holistic assessment of the country's HRH needs in a data-driven manner.
The article has been authored by Vidhi Wadhwani, second year MBBS student, GCS Medical College, Ahmedabad and researcher at Association for Socially Applicable Research (ASAR) and Siddhesh Zadey, co-founding director, ASAR and Commission Fellow, Lancet Citizens’ Commission for Reimagining Health System.
