Abstract
BackgroundRural India has a severe shortage of human resources for health (HRH). The National Rural Health Mission (NRHM) deploys HRH in the rural public health system to tackle shortages. Sanctioning under NRHM does not account for workload resulting in inadequate and inequitable HRH allocation. The Workforce Indicators of Staffing Needs (WISN) approach can identify shortages and inform appropriate sanctioning norms. India currently lacks nationally relevant WISN estimates. We used existing data and modelling techniques to synthesize such estimates.MethodsWe conducted a retrospective analysis of existing survey data for 93 facilities from 5 states over 8 years to create WISN calculations for HRH cadres at primary and community health centres (PHCs and CHCs) in rural areas. We modelled nationally representative average WISN-based requirements for specialist doctors at CHCs, general doctors and nurses at PHCs and CHCs. For 2019, we calculated national and state-level overall and per-centre WISN differences and ratios to depict shortage and workload pressure. We checked correlations between WISN ratios for cadres at a given centre-type to assess joint workload pressure. We evaluated the gaps between WISN-based requirements and sanctioned posts to investigate suboptimal sanctioning through concordance analysis and difference comparisons.ResultsIn 2019, at the national-level, WISN differences depicted workforce shortages for all considered HRH cadres. WISN ratios showed that nurses at PHCs and CHCs, and all specialist doctors at CHCs had very high workload pressure. States with more workload on PHC-doctors also had more workload on PHC-nurses depicting an augmenting or compounding effect on workload pressure across cadres. A similar result was seen for CHC-specialist pairs—physicians and surgeons, physicians and paediatricians, and paediatricians and obstetricians–gynaecologists. We found poor concordance between current sanctioning norms and WISN-based requirements with all cadres facing under-sanctioning. We also present across-state variations in workforce problems, workload pressure and sanctioning problems.ConclusionWe demonstrate the use of WISN calculations based on available data and modelling techniques for national-level estimation. Our findings suggest prioritising nurses and specialists in the rural public health system and updating the existing sanctioning norms based on workload assessments. Workload-based rural HRH deployment can ensure adequate availability and optimal distribution.
Highlights
Rural India has a severe shortage of human resources for health (HRH)
We focused on specialist doctors— physicians, surgeons, obstetricians and gynaecologists (OBGYNs), and paediatricians, general doctors (General Duties Medical Officers—GDMOs) and nurses at community health centres (CHCs), and doctors (MBBS Medical Officers—MOs) and nurses at primary health centre (PHC) in rural areas
We focused on 8 centre-cadre combinations in rural areas—PHC-nurses, PHC-doctors, CHC-nurses, CHC-GDMOs, CHC-physicians, CHC-surgeons, CHCOBGYNs, and CHC-paediatricians
Summary
Rural India has a severe shortage of human resources for health (HRH). The National Rural Health Mission (NRHM) deploys HRH in the rural public health system to tackle shortages. India currently lacks nationally relevant WISN estimates. India is one of the 57 countries with a critical HRH shortage [2]. The national density of doctors, nurses, and midwives was found to be 20.6 per 10 000 people [3] compared to the World Health Organization (WHO) recommendation of 44.5 [4]. It is noteworthy that the current health workers density is a significant improvement compared to the estimated 13.6 per 10 000 in 2005 [5]. There are significant urban–rural differences in HRH with urban areas having four times greater doctor density than rural areas [5]. India took up HRH expansion as a sustainable development goal (SDG)-2030 target indicator for achieving quality healthcare [7]
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