Strengthening nursing and midwifery for enhancing health care services in India
The density of health workers, in terms of numbers of doctors, nurses and midwives per 10,000 population, have always told us that India has far less nurses and midwives than needed. The absolute numbers have increased over the years, however, the ratio has remained low as population growth continues to outpace this growth. Measures such as the integration of ASHAs into the health workforce, and families providing subsitute bedside nursing care in hospitals, hide some of this acute shortage in the public health system.
The Covid pandemic has shown us that more in-patient services are needed at the primary and secondary care level and ad-hoc arrangements made through contractual hiring for nurses and ANMs to fill this gap leads to labour laws violations and exploitation. Some states have wittnessed strikes and walkout as harried nurses refuse to work at low wages or long hours. At the other end of the career pathway, creating senior nursing positions (there are no posts specifically for midwives) and filling them has been a futile process, fraught with procedural tangles because so few senior nurses are in the salary bracket to qualify and those that do have academic backgrounds and are not willing to move. The absence of nurses from health systems decision-making bodies and lack of long term planning for nursing and midwifery has lead to this capacity gap. For example, although midwifery is included in nursing training, staff nurses can be placed in any department of the hospital. This provides flexibility to the hospital adminstrators for placement of nurses in various departments, but leads to lower skills in midwifery so much so that now it is difficult to find nurses who want to specialise in a practice area, since promotions and salaries do not take such specialised practice into account. For hospitals the government still uses the Staff Inspection Unit (SI Unit) figures for nursing staffing despite the High Powerd Committee on Nursing having suggested changes. Most hospitals’ nursing superintendents will admit they are chronically short staffed. In 2021, there is no comprehensive State-wise hospital nursing or midwifery staffing data available, and public and private hospitals are not required to provide their nurse:patient ratio data on an annual basis.
Comprehensive nursing workforce analysis is needed to recommend improvement and prevents the brain drain from this profession to foreign lands were bursing and midwifery are attractive professions within their health system. The recommendations should start at the highest level within the ministry of health and family welfare, the DGHS, and in most state health & family welfare and medical directorates, starting with the inclusion of more nurses or midwives in decision making and filling of all required high-level nursing and midwifery positions by nurses and not held ad hoc or officiating by doctors.
This paper briefly dwells on the global workforce plans developed by the WHO and the barriers in achieving the goals of the Vision2030 HRH numbers in our mixed healthcare system.
The preparations for enhancing nursing and midwifery services to meet national commitments set for the achievement of universal health coverage (UHC), working towards health and wellbeing goals and development towards the Global Strategy for Health Workforce 2030 began early in India. Members of the High level Expert Group on Universal Health Coverage (HLEG 2010) which reported to the Chair of the Planning Commission, reviewed the numbers and submitted a 15-year timeframe. Nearly 10 years on, now I take this opportunity to reassess progress on HRH in nursing and midwifery and to see what processes are in place and explain why progress has been held back despite recommendations made for better career advancement, monetary rewards and additional training and responsibility suggested for these vital professionals within our mixed (public and private) health system.
An assessment of gender and its implications for UHC is essential. One of the simplist actions would be to increase the numbers of nurses and midwives and achieve gender equality in our formal workforce to meet India’s SDG-5 goals. Nursing and midwifery can be attractive careers for young women if gender barriers are addressed. At present female nurses and midwives struggle to balance a full-time career while maintaing socially acceptable, cultural prescribed gender roles. In adequate nursing workforce means that each nurse covers more patient care than is expected, and shift times are less flexible. For example, when there is a shortage of nurses, shift duties become more inflexible and lack of predictability and long work hours lead to burnout. Over time, although working conditions have improved, the overall female workforce participation decline and evidence that higher management positions, heads of unions and greater agency of male nurses to demand their rights suggest that much needs to be done.
Gender concerns must be addressesd if we are to strenghten nursing and midwifery and increase their numbers and quality of work, given that over 85 % of nurses and 100% of auxiliary nurse midwives are women. Among the HLEG’s three key gender recommendations for UHC the second is recommentaion relates to recognition of the role gender plays in the life of a health care provider.
“Recommendation 2: Recognise and strengthen women’s central role in health care provision in both the formal health system and in the home. Address women worker’s concerns about safety,transportation, housing, hygiene and sanitation; as well as maternity benefits, their need for within-district appointments, and stop sexual harassment; Increase the numbers of women professionals in higher management positions through better career trajectories. Ensure representation of women in all health management structures including nurses; Provide more community-based care programmes. Day care centres, palliative care, domiciliary care, and ambulatory care services that can support home based health care provision”.
To understand progress in popularising entry into nursing and midwifery, in the area of incentives for entering the labour market, a framework is provided in WHO’s “Global strategy on human resources for health: Workforce 2030” . The challenge India faces in meeting the nursing workforce goals can be interpreted using this diagram to address the demand and supply side policy levers for increased HRH production and utilisation.
This framework helps us to understand policy levers that shape labour markets in HRH. I would like to use this tp expand on what I consider are the the issues for expanding nursing and midwifery. Starting with the value placed on education leads us to questioning the viability of educational loans as a means of ensuring HRH especially for nursing. It is noticed that the cost of graduate nursing education in the private sector does not allow payback of the student loan even in 15 years, if employed as a nurse in a small private hospital given the current cost of living. Taking the case of female employees especially nurses and midwives I would like to explore further some of the incentives and disincentives to jobs in the public and private sector and suggest why emmigration becomes such an attractive option.
A review of the last 10 years of the Annual Rural Health Statistics which provide HRH employment numbers in the primary health care. It is observed that the posts of obstetricians, and other specialist doctors at the CHC level and rural hospitals have remained unfilled, whereas positions of nurses and ANMs are usually filled, some states have a shortage even on medical officers. The reasons for these two different tragectories for employment between allopathic doctors compared to nurses and midwives are due to differentials in the remuneration structure between the public and private sectors. When looking at incomes, the incentives are such that doctors can earn more in the private sector while nurses earn more in the public sector health institutions. Although public sector doctors in many states doctors can practice or are provided an additional non-practicing allowance (meaning the additional income from practice outside their public health system role is taken into consideration) many still chose to work in the private sector where they have more control over their incomes through complex incentive system in the health care industry which highlight the doctor as the leader of the health team and creator of revenue. Nurses on the other hand are likely to be paid more in the public sector than in the private sector. These are also the same reasons why the private sector in India experiences a high turnover of nurses and the cycle continues with low investment in nursing within the private sector since the industry model does not see a high return on investment. The shocking report that most private sector hospital chains objected to paying nursing a minimum of ₹20,000 per month is telling proof of regard for quality of nursing as a value proposition. We need to do better as we plan for the future.
(The piece has been authored by Leila Varkey Sc.D, Centre for Catalyzing Change and commissioner associated with The Lancet Commission on Re-imagining India’s Health System.)