The Emerging Markets Symposium Opinion Paper on Healthcare Education, Training and Labor Market Issues K. Srinath Reddy, M.D., D.M. (Card), M.Sc, FAMS President Public Health Foundation of India Krishna D. Rao, Ph.D. Head, Health Economics and Finance Public Health Foundation of India The Emerging Markets Symposium Opinion Paper on Healthcare Education, Training and Labor Market Issues - K. Srinath Reddy and Krishna D. Rao, Public Health Foundation of India Introduction As some of the countries are traditionally classified as ‘developing’ accelerate their economic growth and earn the label of ‘emerging markets’, their performance in the area of health care merits close scrutiny. This is not only because of the health care needs within those countries, which need to be addressed efficiently, but also because these health care markets have an increasing connectivity with the health care markets of the more developed as well as less developed economies. This connectivity is especially evident in the case of the health workforce, whose mobility is both an indicator of a dynamic market as well as a cause for concern about the adverse consequences for national health systems. We profile India as an illustrative case study of some of the key characteristics of this conundrum. Health workforce challenges in India The health sector in India faces several critical challenges despite significant achievements since Independence. While the country has made substantial strides in economic growth, its performance in health has been less impressive. An important reason for this is the inability of the health system to provide health care for all. Despite an extensive network of government funded clinics and hospitals providing low cost care, curative health services in India are largely provided by the private sector and serve those who are socio-economically better-off. An unfortunate consequence of this is that fee-for-service private provision dominates the curative care market putting an enormous financial burden on households, particularly the poor - around 70% of health spending is out-of-pocket1. Further, out-of-pocket payments for health care is responsible for 4% of the population falling into poverty2. The lack of qualified health workers in rural areas has been a long standing concern, as a consequence of which many in rural areas are forced to seek care from providers of dubious capability. Reforming the health sector has never been as critical as it is today. Many of the issues facing India’s health sector today and the failure to provide universal primary health care can be traced to distortions in the area of human resources for health. India faces a shortage of qualified health workers. Analysis based on the 2001 Census indicates that the estimated density of all health workers (qualified and unqualified) in India is about 20% less than the WHO norm of 2.5 workers (doctors, nurses and midwifes) per 1000 population, meaning that there is a substantial shortage of qualified health workers in the country. The large geographic variations in the health workforce, across states and rural and urban areas, are important challenges in Government of India. 2005. Report of the National Commission on Macroeconomics and Health. Ministry of Health and Family Welfare. 2 Selvaraj S and Karan A. 2009. Deepening health insecurity in India: evidence from national Sample Surveys since the 1980s. Economic and Political Weekly. vol xliv no 40 1 reforming India’s health workforce policies. The disparity between urban and rural areas is particularly significant - urban areas account for less than a third of India’s total population but are home to a majority (60%) of health workers3. Similarly, the concentration of health workers in the private sector is also a cause of concern, mainly due to the large number of vacancies in the public sector which has taken up the role of providing quality health services in underserved areas. There are important distortions in the production of health workers in India. While there has been an increase in medical colleges in the last decade, it has mostly been due to an increase in private medical colleges in the southern states. Overall, the production capacity of doctors (and nurses) is much higher in states with better health indicators and this reflects the distorted distribution of the country’s production capacity of health workers. Private medical colleges also place a heavy burden of fees on students and their admission procedures are not transparent. The curricula of medical schools, both public and private, are not designed for producing ‘social physicians’ as envisioned in the Bhore (1946) and other Committees. Rather, the training they provide is better suited to the problems of urban India and for employment in corporate hospitals. Nurses constitute an important but neglected cadre of India’s health workforce. Despite their tremendous potential for providing health services to underserved areas, they remain underutilized. Nurses continue to have a low position in the health workforce hierarchy, while in other countries nurse-practitioners have elevated the practice and stature of nursing. Nursing education is also in a state of crisis with many nursing institutes being under-staffed and private institutes providing poorly trained nurses. The adverse nurse-doctor ratio of 0.8 remains a matter for serious concern. Nurses can deliver many of the basic clinical care and public health services, particularly at the community level, at a lower cost than trained physicians. Professional councils such as the Medial Council of India, the Indian Nursing Council, and the Pharmacy Council have been set up by Government Acts to regulate the practice of their respective professions, including education. However, many of these councils serve as little more than lobby groups for their members and have not served India’s health goals well. Further, the existence of these different regulatory bodies, each responsible for important cadres of health workers, fails to provide a synergistic approach to addressing the human resources needs of the country. There is an urgent need for innovation in health related education which encourages cross connectivity across disciplines and categories of health workers. The Indian health system stands to benefit tremendously from the generation of new cadres and competencies that can actively meet the health needs of the country. The broad vision of human resources, in terms of the quantity, composition and quality required for enabling the country’s health system to provide health care for all, is hidden from the limited perspectives of these individual regulatory bodies. Determining human resource needs: planning or the market? Rao KD, Bhatnagar A and Berman P. 2009. India’s health workforce – size, composition and distribution. India Health Beat. Vol 1, 3. Downloaded from www.hrhindia.org. 3 The low number of qualified health workers (e.g. doctors, nurses, paramedics) in rural areas reflects the failure of the labor market. Both the private sector and public sector have been unable to place qualified health workers in rural areas. Supply side market interventions like increasing the number of medical colleges to increase production of doctors and nurses, while important, is not likely to solve the human resources problems such as workforce mal-distribution because of a variety of factors influence employment choice. For instance, there is a strong demand for specialization among doctors with a basic degree in medicine; however, once they specialize there is little incentive to undertake rural services. Further, several institutional constraints in the recruitment of health providers into the government system prevent the active filling of vacancies. Certain planning (i.e. non-market) mechanisms, like compulsory rural service medical students, which are being proposed in India, are unlikely to be successful in overcoming this problem. Lasting solution to this problem most likely lies in an appropriate mix of planning and market strategies according to the context. In India a variety of market and planning mechanisms are being used to address workforce shortages in rural areas. Broadly, these include: Market mechanisms Education incentives: o Reservation for post-graduate studies in medicine in Tamil Nadu (e.g. Tamil Nadu) o Paying the cost of MBBS degree (e.g. Meghalaya) Monetary and non-monetary compensation: o Higher salary to serve in remote areas (e.g. Himachal Pradesh, Uttrakhand) o Locating doctors centrally in remote areas so that they and their families can live in comfortable surroundings even though their posts are in remote areas (e.g. Uttarakhand) Public-private partnerships: o Contracting out of PHCs to NGOs which are then responsible for providing services (e.g. Karnataka) o Contracting in of doctors and other health workers (almost all states) Planning mechanisms Workforce management: o Direct recruitment of doctors to regular positions by the health ministry, bypassing the traditional Public Service Commission (e.g. Haryana) Creating cadres of service providers which can replace allopathic doctors and other health workers at the primary care level: o Rural Medical Assistants (3-year doctors) in place of allopathic (MBBS) doctors at PHCs (e.g. Assam, Chhattisgarh) o ‘Sputum microscopists’ in place of lab technicians at PHCs (e.g. Uttrakhand) o AYUSH doctors in place of allopathic (MBBS) doctors at PHCs (almost all states) The different strategies listed above reflect local context specific solutions to the problem of getting health workers to rural and remote areas. They include a mix of planning and market mechanisms which different states in India have come up with to remedy the health workforce issues they are facing. Primary health care and training The basic degree in medicine (MBBS) in India does not train doctors to serve the primary care needs of the country, particularly for rural service. The content of the MBBS is to prepare students who will be at par in their training with medical students in developed countries. Further, students are not interested in simply acquiring an MBBS degree – they want to specialize. Once they specialize they have a very low probability of wanting to serve at the primary care level. In this regard, it is critical that medical students are trained in primary health care and have exposure to serving in rural areas even if it is for a limited period. However, simply requiring this will not solve the human resource problem. From a training perspective, the structure of the medical degree will have to be changed so that the public health goal - of having physicians trained in primary health care and serving in rural areas, and the aspirations of medical students to specialize are both met. Possibilities in this direction include: o Scrap the MBBS degree and have a direct MD during which students put in rural service at the primary care level for a limited period. o Emphasize primary health care in the MBBS, including posting at PHCs, but make it much easier for students to specialize in their subject of choice after serving some time at the primary care level. Migration of health workers and its control Many emerging countries are a source of human resources to developed countries. The table below shows the major donors and recipients involved in the trade of health workers. Major donors Major recipients Both donor& recipient India, Pakistan US UK Sri Lanka, Philippines UK Germany South Africa, Nigeria Canada Canada Ghana, UK, Canada Australia Germany, New Zealand Germany Source: JLI, Harvard University In India, firm numbers on how many doctors nurses migrate abroad is not available. However, estimates based on smaller studies indicate that a substantial number of them migrate and this is growing. The effect of this migration on availability of health workers within the country is unclear. On one hand there is a loss of health workers and also the public investment made in them through subsidized education. However, it is unclear if migration in is responsible for shortages of health workers in rural areas or in the public sector in India. These shortages are the result of many factors, not just migration. Further, migrant workers are an important source of foreign exchange remittances. If we accept that migration of health workers is not a benefit and should be regulated, there are several strategies to do this short of banning the migration of health workers: o Change the language of instruction from English to local languages so that Indian doctors are not competitive abroad: In Thailand, the medium of instruction in medical and nursing schools is in Thai. This prevents Thai physicians and nurses from participating in foreign job markets. Implementing such a policy in India would be problematic for several reasons. Many students entering medical school have been through English medium schools and will find it very difficult to cope with teaching in a local language, as would the faculty. A larger issue is of which local language should be used as the medium of instruction. Most states in India have their own language and some have multiple languages spoken. If each state adopts a different language of instruction, then the medical graduates will be limited to working within that state and will not be a resource for the entire country. Further, the language issue is a sensitive one in India and any move to promote a certain language in medical education will have repercussions beyond that of medical education. o Introduce work abroad as an incentive for rural service: Allow health workers the opportunity to serve in lucrative foreign markets if they have served in-country, particularly in underserved areas, for a certain period of time. Meeting domestic health workforce needs with foreign health workers In several industries in India (e.g. airlines), the lack of locally available qualified human resources is supplemented by foreign trained professionals. However, the health sector presents some particular challenges in closing the human resource gap in this manner, particularly for primary health services in rural areas. At the primary health care level, it is unlikely that a foreign health worker would be accepted by the community or be able to function due to language and cultural issues. Even posting a nurse/doctor from Tamil Nadu in a PHC in Punjab will bring up the same problems. Specialist foreign doctors coming to work in India is a more likely possibility. However, again it is questionable if they will be willing to fill vacancies in the public sector especially at Community Health Centers and District Hospitals. Further, the added problem of bringing in foreign health workers is that their qualifications are often not recognized by professional councils in India. The different professional councils recognize a very limited number of foreign degrees and this makes it difficult for foreign trained health workers to participate in the Indian market. The most feasible solution to the bridging the human resource challenges in India is to be self-sufficient in health worker needs. This need not mean that one must simply increase production (though this can be a solution), but there are several possibilities of doing more with the health workforce that we have. These alternatives include: o Task shifting in which tasks/duties performed by one cadre of health worker are shifted to another cadre(e.g. nurses providing primary care services instead of doctors). o Multi-skilling (e.g. nurses/paramedical staff become skilled in primary care) o Alternative cadres of health workers (AYUSH physicians, 3-year doctors) o Making underserved areas more attractive for service through monetary and non-monetary incentives. Should India undertake planned export of health workforce? India presently has the largest number of young persons in the world and will continue to maintain a young demographic profile over the next four decades. It has the potential to contribute to the expansion of the workforce in many sectors, not only within the country but also globally. Such a potential exists for the health workforce too. Two types of external markets can be supplied, with varying demands of skill sets. Developed countries may prefer to import highly skilled professionals, suitable for employment in their sophisticated and technology intensive health care settings. Less developed countries may require health professionals trained for delivering health care in low resource settings. Market mechanisms alone may not be able to address this dual demand, apart from failing to correct the problem of internal maldistribution within India, for reasons elucidated above. Planned production of a potentially exportable surplus of health workers may help to streamline this process. The government could contract with developed countries, to undertake planned and externally financed production of highly skilled health professionals and use a part of the revenues for producing health workers for primary health care workers for India and other developing countries. India could also undertake training of health workers from interested low and middle income countries, within India or by establishing educational and training institutions in those countries. This too could be facilitated by a combination of planning and market mechanisms, with the Government acting both as an enabler and as a regulator. While these possibilities exist, the primary concern of India, over the next two decades, would remain the adequacy of health workforce in the domestic primary health care services. Conclusions It is critical that emerging market economies like India comprehensively address the human resource challenges they face for universal health care to become a reality. The poor performance of health is not only contributing to a waste in the human workforce but is also holding back economic growth. The route to health care for all from a human resources point of view, in our opinion, does not lie exclusively in the market or in the planning domain. Either approach has its benefits and limitations. Preference of one over the other should be driven by the context where the problem is occurring. This is exactly what is happening in India with different states attempting to address the human resource challenges they are facing by trying a variety of context specific market and non-market approaches. Further, India should not attempt to solve her human resource problems by poaching from less developed countries or by banning the outflow of health workers. There are several strategies which can be employed to optimize the use of existing human resources or to add to those which are currently available.