Where does India stand with its human resources for health?
The article has been authored by Madhurima Vuddemarry, MBBS student, Rajarshi Chhatrapati Shahu Maharaj Government Medical College, Kolhapur and researcher at ASAR. Siddhesh Zadey, co-founding director, ASAR and Commission Fellow, Lancet Citizens’ Commission for Reimagining Health Systems.
Covid-19 initiated several conversations around the shortcomings of the health systems globally ranging from their incapability to manage the large volumes of admissions to the lack of access to basic medical facilities, tests and treatment options. A core underlying problem plaguing the healthcare community for decades is the shortage and inequitable distribution of health care workers. Broadening the scope of the idea, human resources for health (HRH) go beyond health care workers and are defined by the World Health Organization (WHO) as “people engaged in actions that primarily enhance health”.
Global HRH shortage and disparities in their distribution across regions and countries has been a well-known and one of the most important systemic problems for policymakers and planners. Achieving a certain minimum threshold of HRH has been a priority for nations worldwide. WHO and the United Nations recognising the importance has placed adequate HRH high on the health and developmental agenda and urged countries to do the same. Cross-country analyses have shown that increased HRH density (i.e., HRH personnel per 10000 people) is associated with decreased child and maternal mortality, decreased disease burdens, and improved immunization. Over the course of the past several years, such data have been used to calibrate a minimum number of required HRH for a population of 10,000 (threshold of HRH requirement). The notion is that below this threshold the regions will fail to attain a desirable level of health care coverage in the population.
The 2006 WHO report that came during the Millennium Development Goals (MDG) era estimated that a minimum of 22.8 doctors, nurses and midwives (a group referred to as skilled HRH) are needed for every 10,000 people to ensure that 80% of births are assisted by skilled birth attendants - a crucial health care coverage target. This report estimated a shortage of nearly 4 million skilled HRH personnel globally. Fifty-seven countries including India fell short of meeting the threshold in 2006. If we use the modeled data from the Institute for Health Metrics and Evaluation (IHME), India had 11 doctors, nurses and midwives per 10,000 people in 2006 falling quite below the required threshold.
Ten years later, in 2016, WHO devised a global strategy to improve health by adequate investments ensuring availability, accessibility, acceptability, service utilisation and quality of HRH. The report widened the spectrum of factors used to estimate the threshold for required HRH. Instead of births assisted by skilled birth attendants, a composite Sustainable Development Goal (SDG) tracer indicator was devised consisting of 12 indicators including non-communicable disease management, antenatal care, skilled birth attendance, immunization, sanitation, and family planning among others. Attainment of median score (25% of the SDG tracer indicators achieved) was used to decide the threshold of required HRH to be 44.5 doctors, nurses and midwives per 10,000 people. This report found a global shortage of 11.6 million skilled HRH personnel as of 2013 and forecasted that the shortage would only decrease to 9.9 million by 2030. In 2016, with 15 skilled HRH personnel per 10,000 people, India was below the SDG threshold. Since then India has prioritised achieving 45 skilled HRH personnel per 10,000 people under SDG-3 target for 2030.
More recently, the Institute for Health Metrics and Evaluation (IHME) that leads the Global Burden of Diseases (GBD) studies, modeled estimates for 16 HRH cadres across 204 countries for 1990-2019 and came up with a new threshold for minimum requirement. Here, an effective coverage index constructed in collaboration with WHO that captures universal healthcare coverage (UHC) was used. This index was composed of 23 indicators corresponding to multiple health services for promotion, prevention, and treatment of communicable and non-communicable conditions for population groups from all stages of life. To achieve a UHC effective coverage score of 80 out of 100, the minimum required HRH per 10,000 population were 20.7 doctors (physicians), 70.6 nurses and midwives, 8.2 dentistry personnel and 9.4 pharmaceutical personnel. This study has added to the existing knowledge in multiple ways. First, it looked at HRH cadres beyond doctors, nurses, and midwives. Second, it provided cadre-wise requirement thresholds, which could be useful in deciding investments in cadre-mix across countries. Third, it used data modeled for about 3 decades at country-level to come up with these thresholds compared to the previous reports that used cross-sectional (single year) data at WHO regional levels. Globally, the study found a shortage of over 37 million skilled HRH personnel - 6.4 million doctors and 30.6 million nurses and midwives in over 150 countries. In 2019, India had 6.2 doctors and 10.1 nurses and midwives per 10,000 people largely trailing the thresholds.
HRH scarcity in India is a chronic problem. India has consistently lagged the MDG, SDG and UHC targets. Significant scale up in the form of creation of new seats and retaining every possible HRH personnel is immediately needed to achieve health for all by 2030.
The article has been authored by Madhurima Vuddemarry, MBBS student, Rajarshi Chhatrapati Shahu Maharaj Government Medical College, Kolhapur and researcher at ASAR. Siddhesh Zadey, co-founding director, ASAR and Commission Fellow, Lancet Citizens’ Commission for Reimagining Health Systems.
Recommended Topics