The fault lines of the Indian healthcare system, especially those of our understaffed and under-skilled health workforce, are in urgent need of repair
The Supreme Court has averred that health is a human right, while expressing its anguish at the spate of child deaths in Muzaffarpur. The tragedy in Bihar comes at a time when doctors and patients are locked in an aggressively adversarial relationship across the country. These are searing reminders that we need to urgently repair the fault lines in our health system.
One of those fault lines lies in the state of our health workforce, which is woefully short in numbers and skill to meet the mounting demands on sagging health services. There are far less healthcare providers than needed and those available are severely maldistributed across states, and between rural and urban areas.
How many health workers do we need? The World Health Organisation (WHO) had previously estimated that 23 health workers (doctors, nurses and midwives) would be required per 1,000 population to deliver health services related to the Millennium Development Goals (MDGs). Those services covered maternal and child health as well as major infectious diseases. India’s National Health Mission too pursued the restricted MDG agenda, in which nearly 80% of population health needs were unaddressed.
The Sustainable Development Goals (SDGs) of 2015 expanded the health agenda to include non-communicable diseases, mental health and other conditions that did not feature in the MDGs. Recognising that this full plate of services needed more health workers, WHO in 2016 raised the minimum number of health workers needed per 1,000 population to 44.5. This was based on 12 health indicators and the need to deliver universal health coverage (UHC). The same year, a High Level Commission of the United Nations strongly recommended higher investment in a larger global health workforce, as a potent stimulus for economic growth.
If only qualified health workers are counted, based on appropriate educational qualifications, India has 16 health workers per 1,000 population according to a recent analysis of data from the National Sample Survey of 2016. Qualified allopathic doctors are overall 4.5 per 10, 000 population, but only 1 per 11,000 in the public sector. While we are short of both basic and specialist doctors, the number of nurses is even lower than needed. The ratio of nurses and midwives to doctors is 1.7, while it should be at least 3:1. Midwifery has been subsumed under general nursing, after independence. While it has been estimated that India needs 2.5 million midwives, there are a total of only 1.3 million nurses overall, with many of them lacking adequate midwifery skills.
How do we overcome these challenges? The reconstituted Medical Council of India, with a nominated Board of Governors, is doing a commendable job in reforming a moribund regulatory system of medical education. While doing so, it has recently increased the number of medical undergraduate seats by 15,000 to reach 75,000. Since it has been estimated that we need 100,000 undergraduate seats, it proposes now to permit consortia of large private institutions of repute to start medical colleges or even partner with existing medical colleges to train more undergraduate students. Many such hospitals already run postgraduate medical courses affiliated to the National Board of Examinations (NBE).
Even this may not solve the problem of maldistribution, where several states have few medical colleges and not many large hospitals. It is necessary to upgrade district hospitals in these states and make them robust training facilities for undergraduate and postgraduate medical and nursing education as well as allied health professional training. New medical colleges can be started in linkage with such district hospitals for undergraduate training, and postgraduate training can be affiliated to the NBE. The National Health Mission should consider recruiting fresh medical graduates into a 3-year short service commission to provide for flexibility in posting to underserved states and areas.
There is a need to revive midwifery training programmes while continuing to develop the strength of nursing to full potential by enhancing scale, skills, scope, social status and salaries. Nurse practitioners can become the heart and hands of comprehensive primary healthcare in both rural and urban settings. Digital technology, with decision support systems, management algorithms and tele-consulting, can greatly amplify their effectiveness. Along with community health workers, nurses and other categories of mid-level healthcare providers will be the main service delivery resources in primary care, especially in areas where doctors are scarce. People will not need to travel far to distant hospitals, if primary care needs are met closer to home.
Advanced clinical nursing, needed for multiple specialities, can be developed by starting diplomas and fellowships affiliated to the NBE which already has a wide array of such programmes for sub-speciality training in postgraduate medical disciplines. This will ensure that teamwork, whether in intensive care or surgical theatres, is nurtured through connected and complementary training programmes in common clinical settings. Nurse researchers too must emerge through public health and clinical nursing programmes.
These measures will generate jobs in the many categories of the health workforce, for millions of young persons yearning for productive employment. From the current 6.75 million, the workforce can expand to 11.4 million by 2025. Each year, nearly 3 million youth pass the 12th standard exam in the science stream. A sizeable segment of that group can be channelled into a skilled health workforce. As the numbers swell and the country’s health system needs are saturated, the surplus may also invigorate the global health workforce as countries with ageing populations and shrinking workforce stretch their hands to seek support from India’s demographic bounty. But till then, India and Bihar first!
The author is President, Public Health Foundation of India
Views are personal