India's HRH Challenge:
Initial Findings and Next Steps
Peter Berman
Lead Health Economist, HDNHE
Human Resources for Health, May 28, 09
India HNP in partnership with the Public Health Foundation of India
Thanks to Shomikho Raha, Krishna Rao, Aarushi Bhatnagar and others.
Background
 WHO reports India as HRH deficit country with <2.3 health workers/10,000




population
GoI launches National Rural Health Mission in 2005 – major scale up of
basic health services
2005 public sector has significant deficit of key health workers relative to
official norms
NRHM issues Indian Public Health Standards (IPHS) – significantly
increasing norms
States provided some flexible financing for HRH recruitment and contracting
India AAA: HRH for More Effective Health
Systems
 Proposed multiyear work
 CMU emphasis on flexible, applied work with country engagement and policy


value
Link to states (who control HRH policies)
Phase 1:
• Measuring the health workforce
• “Political Economy” analysis in two states of HRH policy implementation
• Exploratory studies of medical and nursing students’ attitudes and career
expectations
 Phase 2:
• Intervention evaluation
• DCE modeling
Partnerships
 Collaboration with the Public Health Foundation of India
 Engage National Health Systems Resource Center
 Links to states where Bank already engaged with state-level operations: UP
and TN
India: Size and Composition of the Health
Workforce
Health Worker
Density - All India
This chart has the
basic
color
palette to use for charts
(Per
10,000
Population)
You can use this chart and update data or import new charts
Allopathic Physician
Nurse & Midwife
AYUSH
Dentist
Pharmacist
Others
Other Traditional
All Health Workers
0
2
4
6
NSSO
8
10
12
Census
14
16
18
20
Government
Source: National Sample Survey Organisation (NSSO) 2004-05; Census of India 2001;
Medical and Nursing Councils of India; Government of India, Central Bureau of Health Intelligence
Others = Dietician & Nutritionist, Opticians, Dental Assistant, Physiotherapist, Medical Assistant &
Technician and Other Hospital Staff; Other Traditional = Traditional Medicine Practitioner, Faith Healer
India: Public-Private Distribution of Health
Workforce
Distribution of Health Workforce by Sector
Rural
Urban
Allopathic Physician
Allopathic Physician
Nurse & Midwife
Nurse & Midwife
AYUSH
AYUSH
Dentist
Dentist
Pharmacist
Pharmacist
Others
Others
Other Traditional
Other Traditional
All Health Workers
All Health Workers
0
20
40
60
80
Percentage
Non-Government
100
Government
Source: National Sample Survey Organisation(NSSO), 2004-05
0
20
40
60
80
Percentage
Non-Government
100
Government
India: Health Workforce Density across
States
Health Worker Density
(Per 10,000 Population)
JAMMU & KASHMIR
HIMACHAL PRADESH
PUNJAB
CHANDIGARH
UTTARANCHAL
HARYANA
DELHI
ARUNACHAL PRADESH
SIKKIM
UTTAR PRADESH
RAJASTHAN
BIHAR
ASSAM
NAGALAND
MEGHALAYA
MANIPUR
JHARKHAND
WEST BENGAL
MADHYA PRADESH
GUJARAT
TRIPURA
MIZORAM
CHHATTISGARH
ORISSA
DAMAN & DIU
D&N HAVELI
MAHARASHTRA
ANDHRA PRADESH
GOA
KARNATAKA
PONDICHERRY
LAKSHADWEEP
10
16
22
37
-
16
22
37
65
Source: Census of India 2001
TAMIL NADU
KERALA
A&N ISLANDS
Health Workers and Health Outcomes
Measles Immunization
80
100
Infant Mortality
Tamil Nadu
80
UP
Kerala
60
Gujarat
Delhi
40
40
Gujarat
Immunized (%)
60
Bihar
Goa
Bihar
Kerala
Goa
5
10
15
20
25
30
Physican, Nurse and Midwife Density(Per 10,000 Population)
Source: Census (2001), NFHS-3 2005/06
Note: Size of circle proportional to per capita government health spending
20
20
Nagaland
5
10
15
20
25
30
Physican, Nurse and Midwife Density (Per 10,000 Population)
Source: Census (2001), NFHS-3 2005/06
Note: Size of circle proportional to per capita government health spending
Institutional Factors
 State governments vary widely in ability to translate funds in budget into
health workers on the ground
• Health departments don’t recruit – public service commission does
• In UP 18-24 months from approval of posts to appointment letters – majority of
•
candidates no longer available/interested at time of appointment
In TN some creative solutions…
Institutional Factors (2)
 Contractual workers seen as solution, but also bring problems
• In UP, civil service doctors sued state government for unfair employment of
•
contract doctors – as a result all contracting suspended
In TN, successfully implemented …..
Institutional Factors (3)
 Increasing supply of key health workers constrained by conflicts between
central and state regulators
• In UP, most government nursing colleges de-certified by central authorities
• Lack of promotional movement for faculty
• Insufficient faculty for student intake
• 3 year colleges admit one class and keep for 3 years
• ANM schools closed due to lack of funding since late 1990s
• Chhatisgarh instituted 3-year medical assistant degree – struck down by central
regulators
Career Preferences
Medical Students
 90% of final-year MBBS intend to pursue PG Course
• MBBS alone qualifies them inadequately to practice
• Prepared to spend 2/3 years in PG attempts
 Key Job Characteristics preferred
• Salary
• Importance to utilizing skills learnt
• Good living conditions
 Medical Students’ Preferences for the Private Sector
 Greatest benefit of being a Govt. Doctor: Job Security
Career Preferences
Nursing Students
 More amenable to entering the job market after GNM
• Low likelihood of gaining a seat in B.Sc. Nursing
• Seeking a job abroad was much more popular
(But B.Sc. is essential for this)
 Key Job Characteristics preferred
• Salary [Very different range from that of medical students]
• Rated Job Security as the second most important
 Nursing Students’ Preference for the Public Sector
• Pay is better than the private sector
• Greater job security than the private sector
• Offered fixed work timings [esp. important for women with obligations to family]
Phase 1 products





3 full reports (on website)
6 2-4pp policy notes (pending GoI review)
Dedicated website with reports and other links, operated by PHFI
Input to annual HRH training course by NIHFW and HSPH
Other publications to be determined
http://www.hrhindia.org/
Phase 2 work proposed
 3-way collaboration with PHFI and NHSRC. Bank mainly in supporting role
 Inventory of state-level efforts to increase HRH under NRHM (Alliance grant)
 Impact evaluation in Chhatisgarh State of use of physician substitutes in

PHCs (Alliance grant)
Discrete Choice Experiment (DCE) study in 3 states of physicians and
nurses (HNP Anchor TF grant)
Some conclusions for policy and
operations
Emerging opportunities for Bank work in states:
 Focus on institutional factors essential to address supply issues
 Give priority to nurses if we care about rural health outcomes – this will

require changes at policy level
Develop packages of incentives, recruitment, and retention strategy –
multidimension