Investment in human resources for health: Impact on health outcomes

Khushboo H. Balani and Manisha Karne

Department of Economics (Autonomous)
University of Mumbai
khushboo.balani@yahoo.com
Manisha.karne@gmail.com

The Challenge of Human Resources in Health Sector in India

Introduction:Human capital forms an integral part of any economys development. It is both the quality as
well the quantity of human capital that determines the development trajectory of a nation. As
health, and education are important components of human development, the investments made in
health and education and the role of education and health policies becomes very important. The
focus of this paper is on health and the significance of human resources in the health sector. The
potential of the health sector of any nation to deliver rests on three pillars of technology,
financing and the human resources. Human resources are a pivotal part of this arrangement and
are the key determinant for grass root development.
A critical ingredient for building an effective and responsive health system is the health
workforce which includes physicians, nurses, mid wives, health care managers and a host of
other personnel. Today we are facing a challenge whereby the health workforce is confronted by
shortages, migration, issues of quality, accountability, co-ordination and complexity of service
provision to large and diverse populations.
Despite of having highest number of medical colleges in the world, the human resources in
health sector in India fail to comply with the WHO norms of minimum requirements. The
situation is further aggravated by the fact that these resources are unevenly distributed and have
an urban skew. This project aims at understanding the extent of shortage of human resources, the
reasons for this shortage and the short run and long run recommendations to combat this
shortage.
The statistics about total health workforce, health service providers and health management and
support workers as provided by World Health Organization (WHO, 2006). According to this
report the total health workforce is estimated to be 59,220,000 people among whom 64.76% are
in Europe and America. The health service providers are estimated to be 3.45% in Africa as
compared to 31.57% in America. The percentage of total health workforce is estimated as 17% in
2

Africa, compared to 43% in America. These figures highlight the prevalence and universality of
health care shortages. However, these shortages are exaggerated in most developing economies.
These shortages are certainly among the causes of mobility of health workforce and especially of
medical doctors as there are countries which offer better incentives and thus better conditions to
reduce their shortages.
As per the most recent figures reported in the World Health Statistics Report (2011), in case of
India the density of doctors is 6 for a population of 10,000 and that of nurses and midwives is 13
per 10,000. India finds itself ranked 52 of the 57 countries facing an HRH crisis.

Objectives and Methodology:This paper aims at studying the extent of shortage of human resources in the health sector in
India with special focus of the doctors and nurses. A state wise comparison has been done to
examine the extent to which India complies with the WHO population norm of 1 doctor, and 2
nurses and 2 midwives per 1000. It also aims at studying the major reasons for this shortage and
reviews the various recommendations given by various committees with respect to improving
health resources. It calculates the ratios for different states on the basis of latest figures available
regarding the number of doctors and nurses available and to what extent India fall short of
complying with the WHO norm.
Literature Review:At a time when India is grappling with various deficits in achieving its desired level of human
development, examination of its health care system and the shortages it faces becomes
imperative. This paper focuses on the shortfalls in the human resources in the health sector, as
health care system is essentially labour intensive.
In his attempt to measure the demand for physicians' services, Feldstein (1970) finds a positive
price coefficient. His estimates imply a backward-bending supply curve for physicians' services,
he infers that government policies to reduce price inflation, may increase excess demand but will
not decrease and may even increase the quantity of physicians' services provided. The implied
shortages have been growing while accounting for new roles related to the expression of the
3

demand for health and improvements in the welfare of the populations. The shortage of medical
doctors could be also related to the nature of the labor supply curve that may not respond
positively to new incentives. These needs and processes have been leading to the acceleration of
the migration of physicians to economies due to obtainability of higher expected benefits and
better working conditions.
Feldstein (1983) elaborately discusses the health manpower issues in his book titled, Health
Care Economics, whereby he defines shortages in normative as well as economic terms.
According to him, the demand for different health manpower professions is derived demand,
derived from the demand for medical and institutional services. Shortages of health manpower
are often used as an indication of inadequate performance and form the basis for subsequent
government intervention.
The classic example of professional determination of number of physicians needed was the
study by Lee and Jones1, who based their estimate of the number of physicians required in the
population on estimates of the incidence of morbidity and on the number of physician hours
required to provide both preventive and therapeutic services to the population. The policy
proposals that result from normative definitions of a shortage of health manpower are generally
the same: increase the number of trained professionals through increased federal funding.
The report titled Not Enough HereToo Many ThereHealth Workforce in India (2007).,
WHO Country Office for India, Human Resources for Health, High Level Expert Group Report
on Universal Health Cover elaborate on the challenges faced by health workforce and that has
been identified and excessively discussed with the publication of the WHO report (2006) with
the analysis of the patterns, issues and trends related to the human resources operating in the
health systems.
One of the background papers in this report is by Dal Poz, Kinfu, Drager and Kunjumen (2006)
that deal with counting health workers through data with showing the global results. Ranson et
al. (2010) have discussed the priorities for research on human resources for health in low and
Middle income countries. The authors have relied on primary information that is collected by
1 R.I.Lee and L.W. Jones, The Fundamentals of Good Medical Care(Chicago;
University of Chicago Press,1933)
4

way of interviews of different stakeholders to find out about the major problems facing health
workers and the type of research priorities needed. Twenty-one research questions were
identified with some having never received attention in the reviewed literature. They include
incentives for retention and attraction of health human resources to underserviced areas, the
impacts of multiple employments and the use of optimal incentives to enhance quality of health
care.
Most of the literature indicate that the availability, distribution, capacity and performance of
human resources for health varies widely, and many countries have fewer health workers than
needed for coverage of essential health services.
With rapid changes in economic scenario, there are signs of progress emerging in health sector
too. Though several countries are successfully addressing problems of shortages the resulting
improvements in health outcomes will not be sustainable as shortages and inequitable access to
health workers may jeopardize the implications of these efforts. The growing progress and the
new discoveries in health technologies are also likely to increase the demand for new medical
areas implying an enhancement of the level of shortages.
Though shortages of health resources are universal, developing economies are likely to suffer the
most from their implications relative to developed countries. These latter economies have better
planning and management of their medical human resources in both public and private health
sectors.
While the High Level Expert Group (HLEG) report and the WHO report on Health Workforce in
India broadly agree with the problem of shortages and lack of planning and management of these
resources leading to increased migration of health personnel to developed countries, they also
suggest an increased rationalisation and better utilisation of existing resources.
The two reports also emphasise on clearing the bottlenecks in the existing system before creating
new infrastructure. And it does it rightly so, because clearing these bottlenecks is the immediate
short term solution we should aim for; as creating new infrastructure is clearly a long term goal.
HLEG makes recommendations to invest in education, in awareness, in technology and research
and also in creating a pool of management for these workers at various cadres and creating
5

incentives for workforce at various levels. Thus, HLEG recommends leveraging synergies from
various sectors intra-related and inter related to health sector. It is important to emphasise that all
HLEG reports, recommendations are based on the premise that there will be no competitive
market in health care. Years of targeting in India have led to a diversion of resources into some
or other thrust sectors without much noticeable improvement in overall health outcomes.
George Thomas in his article in EPW, titled, Human Resources in Health-Timely
Recommendations, Some lacunae what about implementation? opines that- an attempt at
piecemeal implementation of the HLEG report will lead to another cycle of failure (reference and
year).
Observations:Right from Joseph Bhore Committee in 1946 to Planning Commission task force on planning for
human resources in 11th five year plan many recommendations have been made. Yet, according to
WHO, the human resources for health are inadequate, perhaps even grossly so and are unevenly
distributed with some areas of country very poorly served. HLEG states that existing deficits in
human resources for health system are due to the following reasons:Lack of data: Various state councils (except for Delhi), have not been able to establish a
periodic renewal of registration, the MCI (Medical Council of India) data is cumulative and does
not reflect attrition (due to death, retirement etc), being out of practice or migration of doctors
(within the country or overseas). Further, a doctor may be registered with more than one state
council in cases where one is practising in a State other than the one where s/he is first
registered. This may lead to duplication of registration of doctors. The problem is that the
Councils, particularly at the state level are not able to enforce periodic renewal of registration.
Therefore, there is no mechanism for incorporating attrition, migration or dropouts of workers
once they are in the register. Data on workforce in private sector is hard to come by.
Skewed production of human resources- Post 1980s there has been a shift towards private
sector for health care provision, a split of service provision-preventive care care-otherwise called
public health, has remained largely a service provided by the state, while curative care especially
expensive(and profitable) tertiary care, is now provided mainly by large private hospitals.

As per MCI data, 31,866 new MBBS doctors were registered during the year 2009-2010 and
34,595 students were admitted in 300 colleges for the academic year 2009-2010. Based on
adjusted figures as per HLEGs estimations, the number of allopathic doctors registered with the
MCI has increased progressively since 1974, to 6.12 lakhs in 2011 which yields an adjusted
ratio of 1 doctor for 1,953 persons. This density of 0.5 doctors per 1,000 population is higher
than that of nurse- rich countries such as Thailand and Sri Lanka and much lower than doctor
rich nations like the UK and the USA. Moreover, this density has a strong urban skew and is
concentrated in very few states.
The production of allopathic doctors in the country as per current trends is both inadequate and
uneven. India currently has a density of one medical college per 38.41 lakhs population.
Presently, 315 medical colleges are spread over just 188 of the countrys 642 districts. This skew
is worse in certain states: there is only one medical college for a population of 115 lakhs in Bihar,
95 lakhs in Uttar Pradesh, 73 lakhs in Madhya Pradesh and 68 lakhs in Rajasthan whereas
Kerala, Karnataka and Tamil Nadu each have one Medical college for a population of 15 lakhs,
16 lakhs and 19 lakhs, respectively

Uneven deployment of resources - Health is a concurrent list subject, but most work is
happening at Central level. Constitutionally, the responsibility for the implementation of health
intervention lies largely on the state governments, with the Central government providing policy
directions and financing of health programmes. Political will and pre-existing infrastructure
becomes very important in determining existing health status of states.
The sector was left largely to the states to expand the health network. This has resulted in huge
imbalances in the distribution of all health resources, in general and of human resources in
particular. At present more than 50% of Indias medical colleges, dental and nursing colleges and
other Ancillary medical educational institutions are in Southern states and Maharashtra.
Consensus is that even during the post-independence period, health services were under
financed and biased towards allopathic medicine, urban areas and curative services. Indigenous
systems like AYUSH continue to play only a marginal role. Private sector also tends to
concentrate on better off states within the region.
7

The ratio of rural doctors to the total rural population is far less than the ratio of total doctors to
total population. The median stands at one doctor per 17230 population and six states have a
ratio of one doctor for less than 10000 population.
Disconnected education and training- Currently, there is an Absence of a plan for specialist
doctors. At present, number of places available for training at the post graduate level in India is
not based on any scientific analysis of the need for services. The laissez-faire approach to
medical education has meant that the maximum degree of specialisation has occurred in fields
where financial rewards are the greatest.
Education for health professionals is more clinically and technologically driven towards a
treatment-oriented curative paradigm rather than population-focused primary and preventive
healthcare. There is an increased drive towards super specialization in various medical
disciplines, further pushing the onus and focus of care towards tertiary health models rather than
essential primary care services. The Task Force on Medical Education, NRHM, and the
Independent Commission on Development and Health in India has recommended the revision of
curriculum to focus on primary healthcare and rural orientation.
In India, we have, on one side, the absence of even most basic medical care for large sections
of the population, and on the other, medical personnel with all kinds of specialised skills but not
enough patients.
All previous expert committees have remarked on same factors and suggested remedies,
which do not, seemed to have worked well.
Early post-independence years were marked by Central Government establishing the All
India Institute of Medical sciences, post graduate Institute of Medical Education and Research in
Chandigarh and the Jawaharlal Nehru Institute of post-graduation and research and training
personnel for health sector. In absence of a supporting environment, the leadership role of
Central institutions failed to become a reality, a large number of students left the country and the
institutions gradually drifted into being one among many other medical colleges and hospitals.

An unhealthy rivalry between practitioners of different schools of medicine has been observed
in India. It would be wise to study and integrate all effective therapeutic techniques and finally
create one system of medicine so as to eliminate competition among practitioners, which only
confuses patients.
Most of the equity enhancing programmes are centrally sponsored schemes, time bound and
vertical interventions. They are sponsored and implemented by separate ministries with little coordination let alone synergies between programmes.
We now examine some empirical evidence regarding the extent of shortage of human resources
in India and the extent to which various states in India fall short of WHO population norms.

Growth in human resources in Health sector:

Indias major limitation has been in the production and distribution of human resources across
multiple levels of care. Non-creation of posts at health facilities is pervasive. Over 57% of
required posts for specialists have not been created; the figures are 60% for doctor posts, 72% for
nurse posts, 71% for laboratory technician posts, 68% for radiographer posts and 52% for male
health worker posts. As of March 2010, undue delays in recruitments have resulted in high
vacancies even in available posts at health centres; overall, HRH shortfalls range from 63% for
specialists to 10% for allopathic doctors, and 9% for ANMs, respectively.
Table-1.Statewise change in the number of doctors (in absolute figures)
over the period 2004-2012
(States chosen on the basis of nominal GDP-2012-2013(descending order))

STATE

Maharasht
ra
Uttar
Pradesh
Andhra

20042008
(Absolut
e
change)

20042008
(Percent
Change)

20042012
(Absolut
e
change)

20042012
(Percent
Change)

2004

2008

2012

3897

3988

3433

91

2.335

-464

-11.91

1676

1411

2247

-265

-15.812

571

34.07

1929

2748

320

819

42.457

-1609

-83.41
9

Pradesh
Tamil Nadu

2244

2959

4182

715

31.863

1938

86.36

Gujarat

1183

1542

2197

359

30.347

1014

85.71

West
Bengal

1088

993

837

-95

-8.732

-251

-23.07

Karnataka

2778

3615

4207

837

30.130

1429

51.44

Rajasthan

682

1156

1442

474

69.501

760

111.44

Madhya
Pradesh

757

954

1077

197

26.024

320

42.27

Kerala
Haryana

1013

1235 NA

222

21.915

70

539 NA

469

670.00
0

Bihar

528

862

463

334

63.258

-65

-12.31

Punjab

687

841

768

154

22.416

81

11.79

Odisha

305

331 NA

26

8.525

Jharkhand

183

691

355

508

2174
1

29990

3001
7

8249

India

277.59
6
37.942
1

172
8276

93.9890
7
38.0663
3

Source:-Medical Council of India: 2011-12

Figure 1:

10

2004-2012(Percent Change)
150.00
100.00
50.00
0.00
-50.00
-100.00

In the five years since its inception in 2005, the NRHM gave a major boost to strengthening
primary care human resources by introducing flexibility and financial provision for the
contractual appointments of 10,000 allopathic doctors (including 2,500 specialists), 7,700
AYUSH doctors, 27,000 nurses, 47,000 ANMs and 15,000 paramedical staff. Recruitments were
made at the district level and HRH incentives were introduced for postings in underserved areas.
A long felt need of having one Community Health Worker (CHW) at the village level was
met with the deployment of over 8 lakh Accredited Social Health Activists (ASHAs), roughly
one per 1,000 rural population. These are watershed improvements and set a strong precedent for
reform shaped under a primary health paradigm. Yet, the availability of frontline qualified
practitioners is still lacking; the nearest government doctor or professional nurse is still relatively
far from the home, deployed at the PHC (one for 30,000 population). As a consequence,
communities depend on private, informal, and often unqualified practitioners (quacks) for
treatment, often resulting in further complications. There is, thus, a clear need for building a midlevel cadre of healthcare professionals in the country to take primary health services closer to
people. The Task Force on Medical Education, NRHM, and the Independent Commission on
Development and Health in India has further recommended that at least one medical college be
set up per district in each of Indias underserved districts. In order to ensure adequate provision
11

of healthcare in communities, it is recommended that one additional CHW be provided at the

village level (1 per 500 population) and in underserved urban areas for low income Populations
(1 per 1,000 population).
Source: - Population Census of India, 2011; Medical Council of India, Indian
Nursing Council and Pharmacy Council of India.

States With best doctor population ratio

Goa
Karnataka
Punjab
Tamil Nadu
Sikkim
Maharashtra
Kerala
Jammu & Kashmir

453.4
1
608.6
3
659.4
2
720.2
0
737.4
9
759.3
3
794.6
6
969.8
5

states with worst Doctor population ratio

Rajasthan
Uttarakhand
Madhya Pradesh
Odisha
Bihar
Arunachal Pradesh
Uttar Pradesh
Himachal Pradesh
Haryana
Chhattisgarh

2087.
39
2317.
17
2420.
65
2498.
95
2713.
14
2874.
45
3082.
39
3616.
30
4434.
68
4858.
32
12

7538.
59

Jharkhand
States with medium Doctor population ratio
Gujarat
Andhra Pradesh
West Bengal
Assam
Delhi
India

1131.
29
1195.
86
1458.
18
1504.
02
1714.
24
1317.
86

Source:
RN-Registered Nurses, LHV-Lady Health Visitors, ANM-Auxiliary Nurse and
Midwives, Registered Mid Wives

Inter-State disparity in Human resources in Health: Major states in India

The state wise scenario of health resources is indicated in the following table. There are
interesting observations from the table especially when the human resource status is compared
with the economic progress indicated by the PCY growth or health outcomes of the state.
Generally one expects with better human resource availability the health outcomes to be better
i.e. positive correlation between these two indicators. For measuring health outcomes IMR is
taken as an indicator. The indicator for HRH is physician density which is defined as a ratio of
actual number of physicians available for population norm to expected number of physician for
given population norm. In the table below the all India average for physician density is 0.76 and
all the states having lower physician density than this are not performing well as far as health
outcomes (especially in terms of progress in reducing IMR) leaving very few exceptions like
West Bengal.
Inter-state comparison in density of physicians in India

13

STATES/UT
Haryana
Himachal
Pradesh
Uttar Pradesh
Bihar
Odisha
Madhya
Pradesh
Rajasthan
Assam
West Bengal
India
Andhra
Pradesh
Gujarat
Kerala
Maharashtra
Tamil Nadu
Punjab
Karnataka

Physician
density(WHO def)
0.23
0.28
0.32
0.37
0.40
0.41
0.48
0.66
0.69
0.76
0.84
0.88
1.26
1.32
1.39
1.52
1.64

physician density
1.64
1.26 1.32
0.84 0.88
0.66
0.37 0.28
0.23

1.52

1.39

0.76
0.69
0.41 0.40 0.48 0.32

Density of Physician

States

Human resources and health outcome across states: Few reflections

In the table below the physician density is used as a measure of human resources in health. We
have made a comparison between Physician density, Infant Mortality Rate and per capita income
growth in different states. There is clearly a negative relationship between fall in IMR and
14

physician density. for a higher physician density, the IMR is lower. This clearly indicates the
importance of availability of health professionals in improving the infant survival rate or
reducing the IMR as indicated in the table. The state with higher physician density like Kerala,
Maharashtra, Tamil Nadu and Punjab have lower IMR whereas States like Madhya Pradesh,
Bihar, Assam, Odisha, Uttar Pradesh and Rajasthan have lower physician density and higher
IMR.
In case of per capita income growth, as only latest period is taken in to consideration, the
relationship is not very clear. Hence the correlation between physician density and per capita
income growth is negative and very weak ie 0.21983. This is contrary to the expected
relationship between physician density and PCY growth rate. This may be due to two reasons:
Firstly we have taken only single data point i.e. 2012-13 and secondly the outliers like Bihar,
Madhya Pradesh have higher PCY growth rate for this particular period but are traditionally
laggards as far as both income growth, physician density and IMR is concerned.

IMR, Physician density and Per capita income growth for major states in India

15

States

Physician
Density

IMR

Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Odisha
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
India

41
55
43
38
42
36
32
12
56
25
53
28
49
21
53
32
42

0.84
0.66
0.37
0.88
0.23
0.28
1.64
1.26
0.41
1.32
0.40
1.52
0.48
1.39
0.32
0.69
0.76

per capita
Income growth
2012-13
(in per cent)

4.5
4.6
13.9
6.6
5
5.1
4.2
7.7
8.6
5.8
5.2
3.9
2.9
3.5
3.6
6.4
2.1

The
National

Board of Examinations (NBE) should be strengthened to enable post-graduate medical education

in qualified hospitals not attached to medical colleges, to produce required number of specialists
as per national needs. This will also help to provide required faculty for medical colleges.
If universal healthcare is what government aspires for, it must give shape to one system of
healthcare for all. A private, for profit health system cannot co-exist with a state health system.
Private system will inevitably cannibalise a large number, if not the majority, of the most
effective personnel from the state system will always be seen as second class.
Quality, responsiveness and accountability, all attributes are generally believed to be absent
in state-sponsored health services. However, it is high time that India takes these issues seriously
so that the dream to have a high quality, egalitarian healthcare system, a basic service in any
civilised country becomes a reality.

16

We find that among the major states in India, states like Kerala, Karnataka, and Tamil Nadu are
performing extremely well, while states like West Bengal, Uttar Pradesh and Bihar need to
urgently improve their human resources status. North East India in general does not seem to
comply with the doctor population norm, with the exception of Mizoram. The State of Haryana
also falls very short of the ideal doctor population and nurses population norm.
We also notice that with respect to number of doctors registered some states seem to have an
extremely haphazard pattern, especially the states of West Bengal, Andhra Pradesh and Bihar. We
do not see any clear trend in these states. On the other hand, states like Gujarat, Tamil Nadu, and
Rajasthan have shown some great improvement over a period of time. The state of Tamil Nadu
can almost be used as a model for improvement in health resources.
Policy Recommendations and Conclusions:Deficiencies in HRH, both in numbers and skills, are major contributors to the suboptimal
performance of the health systems in these areas. The development and deployment of HRH in
India over the last six decades has been steered by various Government-commissioned expert
committees Notable amongst these are the Health Survey and Development Committee headed
by Sir Joseph Bhore (1946), the Health Survey and Planning Committee lead by Mudaliar
(1961), the Chadha Committee (1963), the Kartar Singh Committee (1974), the Shrivastav
Committee (1975), the Medical Education and Review Committee led by Mehta (1983), the
Bajaj Committee (1986), the Mukherjee Committee (1995), the National Commission on
Macroeconomics and Health (2005), and the Planning Commission TaskForce on Planning for
HRH (2007). The Bajaj Committee for health manpower planning and development presented
the first ever assessment of HRH availability in India. It recognized that health systems and
human resources development were isolated from each other across ministries. The Committee
made projections for rural HRH requirements for the millennium along with recommendations
for building human resource capacity in educational institutions.
The Sixth Plan (1980-85) expressed dissatisfaction with the existing model of health serviceswith its emphasis on hospitals, specialisations and super specialisations and highly trained
doctors-which was availed mostly by the well to do classes. The plan emphasized the
development of a community based health system. It emphasized that horizontal and vertical
17

linkages had to be established among all inter related programs like water supply, environment,
sanitation, nutrition, education, family planning , maternal and child health programs.
The National Commission on Macroeconomics and Health (NCMH), 2005 identifies human
resources as one of the key drivers of the health system. The Commission has noted the shortage
of human resources for health of all categories, lack of teaching faculty, low quality of
instruction and skill acquisition, neglect of community medicine. The key recommendations for
human resources include:

Urgent need for establishment of a Commission for Human Resource Development and
Medical and Health Education for promoting excellence in health care and human

resources for health.

Need for a live register and database for all categories of medical and paramedical

personnel and regular updating of the same by the respective professional councils.
Sufficient incentives, financial and non-financial to be given for attracting medical
teachers to join and continue in pre- and para- clinical specialities in medical colleges.

India needs to create appropriate incentives for human resources at all levels to ensure that its
population is adequately served and if it aims at reversing the tide of brain drain which is costing
it dear. The policies also need to orient themselves towards promoting preventive care and
strengthening the base of primary care. While NRHM is a step in the right direction, a lot needs
to be done to address the lacuna.
The WHO population based norms is a necessary but not a sufficient standard to be aimed for
universal health coverage. Population norm does not take into account the varying
epidemiological, geographical and socio demographic patterns across different states, across
different communities and between rural and urban areas and within states. Neither does it take
into account the actual availability of different types of providers or extent of private sector and
voluntary sector involvement in health care delivery at the community level.
The need of the hour is to pool all human resources- formal and informal, allopathic and
AYUSH, doctors, nurses and paramedics- in appropriate ways. Through systematic forecasting
and planning that responds to local needs rather rigid norms, human resources can be better
deployed. Through multiskilling and different types of skill mixes, essential health services can
be provided even if certain categories of specialist staff are not available.
18

On human resources, the HLEG emphasises increasing numbers exponentially and creating a
substantial number of mid-level professionals. Its first proposal is adding more CHW
(Community Health Workers) at village level so that there is one for every 500 in rural areas, one
for every 1000 in urban areas. CHWs should be from area served, its important because
government jobs are much valued at the lower levels and a large number apply for them. CHWs
are unable to meet their obligations if they have one of the major problems of the state sponsored
health care and bring the system into disrepute.
Intermediate level medical personnel are an essential part of many health systems in UK.
Obstetric care is provided by qualified mid wives. Government implements it in spirit of
universal health care system. HLEG recommends increased financial allocation and expansion of
educational centres to train mid-wives; nurses and doctors in areas of country that have severe
shortage. Nurses and Mid-wives are proposed to increase in country in four phases from 2012 to
2022. Report Remarks that NRHM had to appoint far fewer nurses than required due to nonavailability. Hence, theres an urgent need to build this base of intermediate, qualified health
personnel in India.
In order to ensure an adequate number of health workers for Universal Health Coverage, it is
necessary to augment the health workforce at different levels. The HLEG recommends widening
and deepening the base of the pyramid to strengthen the healthcare system for the delivery of
primary and preventive healthcare. Meeting the requirements of UHC will call for an
improvement in the countrys present doctor-to-population ratio from 0.5 per 1,000 persons
based on our estimates to a well-measured provision approaching one doctor per 1,000 persons
by the end of the year 2027. Thus, we recommend increased financial allocations for
strengthening physical infrastructure for SHCs, PHCs and CHCs, ensuring HRH availability
through the creation of new educational institutions for medical, nursing, midwifery.
Theres also a need to increase the number of medical colleges in underserved areas,
increasing the number of seats in government medical colleges and reserving 50% of the seats in
private medical colleges for local candidates.
In UK, Prime Minister, President and Queen utilise services of public hospitals-enormous
public trust in state health system in these countries. The rich and powerful in India, in both
public and private sector use private corporate hospitals or go abroad for treatment. All centres of
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excellence including AIIMS not excellent. Thus, it is a matter of perception in India, despite
booming medical tourism in the country.
HLEG also recommends improving the quality of health education to produce professionals
appropriate to the needs of the country. This has been recommended in every report on health
care in India. It has never happened primarily because the private health sector in which more
than 85% of health professionals now work, can only be urban, specialist and high cost if it has
to realise the profits for which it has been established.
Overall shortages are commonly aggravated by skewed distribution within countries and
movement of health workers from rural to urban areas, from public to private (profit and not for
profit), or to jobs outside health sector. The contributing factors include insufficient investment
in pre-service training, migration, work overload, infrastructure, inadequate growth opportunities
and work environment issues, infrastructure, technical safety amongst others.
McKinsey and Company 2002 reveals that if India were to meet a hypothetical target of one
allopathic physician per 1000 population in 2012, the number of students in medical colleges
will have to double, and even then more than 300000 non formal practitioners will have to be
involved to provide basic allopathic treatments.
The public sector is plagued by shortages of human resources and supplies as well as lack of
managerial capacity to manage its elaborate infrastructure. Organizational hierarchies and
divisions create additional bottlenecks that can only be addressed through systematic restructuring and decentralising. Above all, the public sector orientation to managing human
resources must recognise and put in place modern human resource development know how and
principles. The approach must shift from traditional personnel administration systems to more
modern human resources development policies and practices.
Narrowing the wage differentials between the public and private sectors is clearly an
important policy tool to attract medical professionals into the public sector. Incremental increases
are not sufficient; salaries must increase several folds to attract the best talent back into the
public sector. Thailand has attracted back medical professionals through a reverse brain drain
program offering generous research funding and monetary incentives(Wibulpolprasert,2003).In
India, a cost analysis is needed to compare the costs of setting up new medical colleges(around
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60 new colleges have been proposed by the NCMH) on the assumption that a handful of the
graduates will make their way into the public sector, versus the costs of substantially increasing
current staff salaries and attracting a larger proportion of the available pool of doctors into the
primary care setting.
Working conditions of health workers are poor as facilities are chronically understaffed and ill
equipped with the basic supplies. It has been estimated that 50% of students from AIIMS have
migrated overseas as well as internally to the private sector. (GOI, NCMH, 2005)Most of the
migration in health sector is permanent. The main advantage is due to availability of low cost,
well trained, high quality health care providers from India. Active international recruitment by
national health systems has generated a particularly high level of cross border mobility among
nurses. For the available data for the year 2002 India was the most important source country for
registered nurses under HIA category to the US around 81,091 nurses compared to 15,838 for
China, 5,509 for Philippines. (WTO)
Indias mandate for Universal Health Coverage (UHC) depends, to a great extent, on adequate
and effective Human Resources for Health (HRH) providing care at primary, secondary and
tertiary levels in both the public and private sectors. States are presently struggling with the
complexities of escalating human resource costs, additional demands on the available health
work force, compounded by chronic HRH shortages, uneven distribution and skill-mix
imbalances. Indias health system is among the countrys highest employers and absorbs almost
two-thirds of the health budget for allocations in deployment, education, training, etc. Reform of
HRH will therefore be the keystone of Universal Health

Based on cumulative data from comparative time periods (2001-2005), the NCMH reported
in 2005 that India had a doctor: population ratio of 0.5 per 1,000 persons in comparison to 0.3 in
Thailand, 0.4 in Sri Lanka, 1.6 in China, 5.4 in the United Kingdom, 5.5 in the United States of
America and 5.9 in Cuba. The ratio of 2.19 nurses and midwives per doctor ranks India lower
than Sri Lanka (3.94) and Thailand (5.07).This makes it necessary for India to simultaneously
augment the number of doctors and improve the nurse/midwife ratio to doctor in the coming
years. These HRH shortfalls have resulted in skewing the distribution of all cadres of health
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workers, such that vulnerable populations in rural, tribal and hilly areas continue to be extremely
underserved. For example, in 2006, only 26% of doctors resided in rural areas, serving 72% of
Indias population. Another study has found that the urban density of doctors is nearly four times
that in rural areas, and that of nurses is three times higher than rural areas.

References:

Baru,R.,Acharya, A., Acharya S., Kumar,S., Nagaraj K.,(2010),Inequities in Access to

Health Services in India: Caste, Class and Region, Economic and Political Weekly,

September 18,2010, Vol.XLV,no.38,pg:-49-58

Feldstein, Paul (1983):chp.13 Health Manpower Shortages: Definitions, Measurement,
and Policies, Health Care Economics,2nd edition, Wiley Publishers,pg:303-337

Dal Poz, M.R, Kinfu, Y., Drger, S. and Kunjumen, T. (2006), Counting health workers:
definitions, data, methods and global results, Department of Human Resources for Health
World Health Organization, WHO report

Lee R.I. and L.W. Jones, The Fundamentals of Good Medical Care(Chicago; University
of Chicago Press,1933)

Ranson, Chopra, Atkins, Dal-Poz and Bennett. (2010). Priorities for research into human
resources for health in low- and middle-income countries. Bull World Health
Organ vol.88 n.6 Genebra. http://dx.doi.org/10.1590/S0042-96862010000600012

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Thomas,G.,Human Resources in Health(2012): Timely Recommendations, Some

Lacunae and What about Implementation?, Economic and Political Weekly, Feb 25,2012,
Vol. XLVII.,No.8,pg:-67-70

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