Rural areas need human resources for health
The article has been authored by Vinayak Mishra, general practice registrar, Blackpool Teaching Hospitals NHS Trust, Lancashire, UK and researcher, Association for Socially Applicable Research (ASAR), Pune, Gaurav Urs, intern, Adichunchanagiri Institute of Medical Sciences, Karnataka and researcher, ASAR and Siddhesh Zadey, co-founding director, and Commission Fellow, Lancet Citizens’ Commission for Reimagining Health System.
The Covid-19 pandemic has uncovered the chronic problems in Indian health care including shortage of health care workers, health inequities, and marginalisation of evidence-based public health. When the second Covid wave struck India, with over a million people infected daily, the government converted wards into intensive care units and nursing homes into specialist Covid-19 hospitals. Dr Devi Shetty, one of India's most renowned doctors, remarked, "Beds do not treat people. Doctors, nurses, and paramedics are the ones who do it."
Health systems require human resources for health (HRH) to ensure healthcare for all. According to the World Health Organisation (WHO), HRH scarcity primarily affects low- and lower-middle-income countries (LICs and LMICs) like India. Since 2000, India's public health expenditure has been below the recommended 5% of the country’s gross domestic product (GDP). This protracted lack of investment has impeded HRH scale up, recruitment, and training and resulted in budgetary constraints that limit their employment, particularly in rural areas. The past two decades have seen a modest rise in medical and nursing colleges leading to an increase in the number of doctors, nurses, and paramedical workers in India. However, problems still persist in empowered action group (EAG) states, including Bihar, Odisha, Jharkhand, Chhattisgarh, Madhya Pradesh, Rajasthan, Uttar Pradesh, and Uttarakhand. The lack of HRH in these states contributes to higher mortality and lower life expectancy.
A recent scoping review on Indian HRH found that as of 2012, HRH density (per 10,000 people) was roughly one-third of the WHO’s recommended standard, which falls significantly if we only consider qualified HRH. Despite rural areas accounting for over 70% of the Indian population, the review pointed out that the urban-to-rural ratios for doctors, nurses/midwives, and dentists were 3.8, 4.0, and 9.9, respectively. This disparity extended to medical practitioners' education and qualifications. Only 18.8% of rural allopathic doctors held a medical degree compared to 58.4% of urban allopathic doctors, localising India’s quack problem to rural areas. Rural areas also have a severe scarcity of specialist doctors in public healthcare centres. Further, scarcity in the public sector HRH can make the population more dependent on private sector HRH which can lead to catastrophic health expenses. Unfortunately, the private sector is unregulated and includes unqualified and unlicensed medical practitioners as found by the same scoping review study. For example, only 39.7% and 57.1% of private medical practitioners were qualified (i.e., had proper education and licence) in the North and West India, respectively.
The plethora of issues that HRH experience in rural settings provide further insights into rural HRH shortage. Poor housing standards, fear for personal safety due to rising violence against HRH, limited educational opportunities for their offspring compared to urban areas, and minimal recreational activities to maintain one’s work-life balance hamper HRH recruitment in rural areas. Professionally, HRH personnel have to tackle tassels with rural administrative officials, lack of infrastructural resources, having to care for a patient base that cannot afford healthcare and is at times unwilling to conform to new practices in medicine, and, a constant reminder of the glass ceiling for career advancement.
However, Indian policy-makers have a menu of options that could be used to alleviate the health system stress. Firstly, recruitment of fresh medical/nursing college graduates interested in rural service through a champions model at an early career stage could be used to create advocates for the cause. These champions can help spread the message to their peers about the value of rural service. Secondly, investing in long-term incentives such as merit-based scholarships, support for children's education, and opportunities for spouses is critical. Finally, involvement in leadership roles, engagement with community stakeholders, and participation in administrative decision-making can strengthen the sense of ownership among rural HRH and help them gain their patients' trust.
The article has been authored by Vinayak Mishra, general practice registrar, Blackpool Teaching Hospitals NHS Trust, Lancashire, UK and researcher, Association for Socially Applicable Research (ASAR), Pune, Gaurav Urs, intern, Adichunchanagiri Institute of Medical Sciences, Karnataka and researcher, ASAR and Siddhesh Zadey, co-founding director, and Commission Fellow, Lancet Citizens’ Commission for Reimagining Health System.
