Investment in HRH to improve availability of health workforce has gained increased attention in recent years [2, 5]. In India such investments also have potential to enhance female labor force participation and formalization of labor market [15]. These discussions on enhancing the investment and policy attention to health workforce-related issues has assumed centrality in the presence of the COVID-19 pandemic.
In the present report, we presented different dimensions of HRH in India, along with existing and emerging challenges which need to be addressed for improved availability of health workforce in the country as a whole and at the state levels. We used two nationally representative data sources on health workforce: (i) stock of health workforce from the NHWA 2018 and (ii) National sample survey data (NSSO) 2017–2018 on labor force to identify HRH challenges and areas of investment in HRH in India. Our estimates from the NHWA data are almost similar to the results as reported in a recent WHO report [15]. However, NHWA and NSSO-based estimates in the present study reflect widely varied estimates on the size of health workforce with the NHWA-based estimates significantly higher to the NSSO-based estimates.
Several reasons have been highlighted explaining the difference between the estimates of health professionals from the NHWA data and health workers as reported in the NSSO data [14, 18]. Most of these reasons are related to the fact that a large proportion of the health professionals registered with different councils and associations are not part of the current health workforce in India. One widely discussed reason is the migration of qualified health professionals from India to other developed countries [8, 13, 35, 36].
In addition, there are reasons related to the veracity and updating of the NHWA data. For instance, the NHWA data are collated from different professional councils, which do not maintain a live register and do not require renewing the registration. The information they provide is fraught with non-adjustment of health professionals leaving the workforce because of death, retirement and double counting of workers because they have registered in more than one state [14, 18].
However, one of the most important reasons of this differential estimate is that the NHWA provides total stock of health professionals, but not all of them are active in labor markets. Using NSSO, we reported in this paper that a substantial proportion of medically qualified individuals, overwhelmingly women, is currently not a part of workforce, either because they are currently unemployed but available for work or they do not want to join labor markets. This is particularly amplified for nurses/midwives, for whom the difference between the registered and active workers is the highest. If we apply these proportions (% employed) over the NHWA stock data, we come to pretty close estimates from the two sources.
Despite the differences in estimates of health workforce across the two main sources of information, both the sources indisputably reflect skewed distribution of health workforce across states and inadequate skill-mix ratio.
AYUSH practitioners are recognized health professionals by government of India and they use indigenous system of healthcare. Use of indigenous knowledge in health system is not unique in India. Such system exist in many developing countries including Bangladesh, China and South Africa [37,38,39] and the Traditional Chinese Medicine was also used as a safeguard against SARS and COVID-19 in China [40]. In India, a large section of population has significant belief in AYUSH system and for many chronic conditions AYUSH is often preferred over modern healthcare by a large proportion of population [41, 42]
Density of health workforce with respect to population is an important indicator of availability of health workforce. Density of allopathic doctors and nurses who are active in labor market are as low as 6.1 and 10.6, respectively, per 10,000 persons (16.7 in total), which is well below the WHO threshold of 44.5 doctors, nurses and midwives per 10,000 population. If we add dentists and AYUSH professionals, the total active health workforce density comes to be approximately 22 per 10,000 persons. The present study clearly reveals that new investment for improving the size of active health workforce is the most important area which needs policy attention in India.
In addition, we also find a sub-optimal skill-mix between doctor and nurse and doctor and allied health professional. Size of traditional medicine practitioners (including AYUSH) in India is quite sizeable. Total number of active AYUSH practitioners is almost 70% of the total number of active allopathic doctors.
However, the number of nurses per doctor is less than 2. This number is lower to 1 if we consider BSc Nursing qualifications. In most OECD countries there are 3–4 nurses per doctors [8]. We find that although total stock of nurses in the country is approximately 3 times number of doctors, a large proportion of nurses are not actually active in labor market. In order to increase nurses’ participation in active health workforce, creating a smooth employment environment for nurses may be another area of policy intervention. There is a need to make balance between densities of doctor and nurse both for a better availability of health professionals and skill-mix. Similarly, doctor/allied health professionals’ ratio is also very poor which needs attention. The Global Strategy report [4] and other similar studies [43] also emphasized creation of enough allied health professionals through improved training and educational infrastructure.
Skewed distribution of health workforce across states and rural–urban setting is yet another area which needs policy attention. Nearly two-thirds of all health workforce in India is concentrated in urban areas leaving rural population either in extreme unmet need of health workers or to avail their services by travelling in urban areas or both. The lop-sided distribution of health workforce is also pronounced across Indian states. Most of the less developed states such as Bihar, Jharkhand, Odisha, Rajasthan, Uttar Pradesh, etc., reflect the acute shortage of health workforce. To understand the reasons of such skewed distribution across states and to understand regional level complexities, a more detailed and deeper study is required.
As far as public–private division of health workforce is concerned, the bulk of doctors’ employment is in private sector while nurses are almost equally distributed across public and private sector. Public sector seems to be sole employer of traditional medical practitioners. These lop-sided distribution of health workers not only creates shortage of trained health workforce in many states and rural areas, but also leads to unequal skill-mix across different types of health workers in different settings. These findings are in conformity with earlier studies [14, 20].
The public sector is also challenged by a high rate of vacancy of sanctioned positions [44]. While the shortage is most pronounced for specialists at Community Health Centres, the shortages are prominently witnessed across the states for various positions. The existing vacancies are attributed to diverse reasons that range from barriers in recruitment, litigations against recruitment processes and premature exits from the system, especially in contractual positions. Filling up existing vacancies in government sector requires urgent policy attention.
An analysis of the health workforce projections suggests that the estimated density of skilled health professionals (doctors, nurses and midwives) per 10,000 population is unlikely to alter from current levels by 2030 if the current rates of growth are sustained. While we are to witness an absolute rise in numbers by 2030, the density of the health workforce is unlikely to change by 2030. AYUSH represents Indian systems of medicine which are predominantly accessed by people of Indian origin, and their inclusion might introduce difficulty in creating comparisons with other countries. Nonetheless, we feel that since there is a significant government emphasis and investment in their training and deployment, as well as them sharing a large clientele in the population, they merit an inclusion in the overall workforce numbers. We have presented the AYUSH numbers as distinct from doctors, but we have included them in the calculation of the overall skilled health worker density.
At the present level of the growth in the supply side, the skill-mix ratio of doctor: nurse is unlikely to alter by 2030. A near 200% growth in the supply side for nurses will improve the doctor: nurse ratio to 1:1.5 by 2030. This will require a further rapid scale-up of nursing programs. The High Level Expert Group report for the Planning Commission in 2012 [45] had suggested a ratio of 1:2:1 for doctor:nurse:ANM for India. For achieving this number of nurses by 2030, simultaneous efforts will have to be undertaken on the demand side of the market as well. The roles for nurses and the functions that are performed by them will need closer attention.
The analysis in this study throws several points for policy interests as follows:
Expanding the supply side of the health workforce The expansion of medical educational institutions (medicine, nursing, dentistry, etc.) should be prioritized across geographical regions with a shortage of health workforce and the passed out from these institutions should be encouraged to work in local areas. Thailand represents a good example of effective implementation of rural retention policies for medical doctors [46]
Growth in the number of nurses in the workforce needs priority attention The creation of new infrastructure/institutions for nursing may be a medium- to long-term intervention. Also, efforts should be taken to expand the capacity and quality of existing institutions to train the nurses.
Increasing participation of trained personnel in the workforce A significant proportion of the trained manpower, especially women, is not present in the workforce. Strategies for re-skilling these graduates and attract them in labor markets should be worked out.
Balancing the skill-mix The existing skill-mix is doctor-centric with a lower number of nurses. An emphasis on significantly increasing nursing supply and retaining the nurses in the workforce needs to be evolved at the national level. The specific role of task-shifting and its impact on patient-care and well-being will need greater attention.
Fast-tracking recruitment and deployment for public health facilities Improve effectiveness of recruitment processes by walk-in interviews or contractual/flexible norms of engagements to reduce the existing human resource gaps in public sector institutions, particularly at the primary levels.
Harnessing technology Covid-19 has highlighted the potential to make more effective use of new and emerging technology to improve the delivery of care, to enable rapid and effective communications, and to improve access to care via e-health and m-health interventions. This is an area where investment in technology and in training the workforce can have dividends.
Up-skilling programs for less qualified care providers There is a section of the health workforce which has lower than desirable qualification as reported in the NSSO data. This issue needs deliberation within the Councils and the Ministry of Health at the national level to identify the mechanisms to address the issue. While we do not recommend their formalization in the workforce in the present form, the government can consider up-skilling programs to improve the quality of services and engage them in a range of care giving and non-medical health services.
Improving HWF information A significant overhaul and improvement of data on registration of health professionals with live registers of health professionals at the country level is required, with a regular/periodic update and adjustment of the data base. The presence of live registers will replace the reliance on estimates from surveys and give a clearer picture for prompt decision-making and workforce planning for the future, as well as contributing to ongoing quality assurance of the registered professionals.
Implementing the above recommendations will require substantive increase on investment in the health workforce, which will contribute to inclusive economic growth in India.