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Status of human resources for health in India -Thamma Rao

Status of human resources for health in India -Thamma Rao






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  • As Advisor HRH at New Delhi, I am delighted that the IPH has taken the initiative towards HRH reforms -
  • Most of the committees headed by the then DGHS or other technical heads - What were Achieved till NOW - Managers were too preoccupied with the heavy priorities and too little time for long term prospectives - When we are busy, we don’t even remember our food - HRH met the same fate all these years
  • Health care often seen as doctor in the hospital and then the nurse for nursing care, pharmacist to give drugs, Technician for diagnostics, Attender for dresssing / cleaning the wounds ………. - How about the prevention - crucial Public Health
  • The preventive health or the Public Health HRH are less visible except for the high intensity campaigns such as Polio. Prioritisation of tertiary / secondary care is more often at the cost of preventive / primary health care.
  • The 13 teams of CRM explicitly expressed the HRH as major constraint in 12 out of 13 States visited. First fore most being critical shortfalls in HRH -- HRH Availability, Competence & Productivity
  • Ironically, India producing largest number of skilled workers, has very low HRH. China has more doctors and Lab. workers; Cuba almost 10 times more doctors The scenario is no different for nurses, Lab. Workers etc. This is in spite of our awareness from Pre-independence era – Govt. of India committees on HRH - Bhore (1946), Chadha (1963), Kartar (1973), Srivastava (1975) as well as NHPs, NPP emphasised HRH issues. Lack of HRH DATA IS THE issue even at the State level. HRH equity, quality & Accountability can only be ensured based on the demographic & epidemiological data, health status of the population and most importantly the health facilities provided ……..
  • NRHM - Enhanced availability of HRH was started with 2nd ANM - extended to MOs, Specialists, Lab Technicians …… Contractual MOs 6906, AYUSH Drs 5321, Specialists 2266, Nurses 22789, ANMs 39633, Paramedics 5428 & ASHAs 6.96 lakhs: States filling vacant posts: Incentives - Difficult area / Rural service a preference for PG Availability of Untied Funds improved HR morale & performance
  • States with Good Infrastructure & Higher HRHDeliver Better Health Care. Five year plans ensured progress. Vision of ID Dev. - I & II plan achieved during 80s and stagnating since then - Is it lack of wisdom to implement or finances or realisation of non-availability of HRH.
  • This is just to reconfirm that with NRHM initiatives of untied funds etc, eased away the physical infrastructure bottlenecks - and the time has come for greater thrust on the other critical component - HRH - for health care outcomes - the higher the output of HRH the better Immunisation levels and lesser IMR.
  • Non- availability of adequate HRH is the constraint in High Focus States - WHO recommends HRH of 25 - In India variance in States is too wide - 10 in Bihar to 38 in Kerala
  • With in the States, even good performance States, there are pockets of districts / Blocks even for Immunisation of Children.The good news is that some of the districts in Bihar, UP, Rajasthan etc are performing better than some of the districts in Kerala or Tamilnadu
  • As per details of DLHS -3 data available for the 14 States - over 85 % of Women who availed the Govt. facilities stated that the Staff were physically available at the facilities (Bihar very marginally less at 79%) thus clearly indicating positivity of HR Accountability. However, the perception for Quality ranged widely with low of 35 % to higher levels of over 60% in Pondy, Goa, Kerala Orissa
  • Rural area incentive ranges from Rs. 3000 to 5000 for MOsThe incentive ranges by Rs.5000 to 10,000 for MO & Specialists pm Incentive for ANM is Rs.1000 pm and GNM is Rs. 2000 pmJharkhand : support for insurance coverage of the ANM, Staff Nurses, other support staffs and Doctors posted in the identified Naxalite areas.Jharkhand : Free daily transportation to remote area in Naxalite affected areas Maharashtra:MOs & Specialist incentive - Rs. 1000/- in tribal area and Rs. 1500/- in extremism affected areasANM Package – Rs. 6000/ month for rural area, Rs. 7000/month for tribal area & Rs. 7600 /month for extremism areasStaff nurses & LHV – Rs. 8000/ month for rural area, Rs. 9000/month for tribal area & Rs. 9500 /month for extremism area Madhya Pradesh10,000/pm to regular and contractual specialists ( O&G, Paed), 5,000/pm to MO( regular and contractual) staying at the Facility Incentive of 1 month salary for field staff posted at underserved districts in Nagaland
  • Quality of care very critical and it can be only through adequate training – Students in their final months of training were interviewed and ……
  • DLHS -2 (2002-04) DLHS -3 (2007-08)
  • Our recent visit to Drass & Kargil areas of Kashmir as part of the Common Review Missions was an eye-opener as the only request from the president of a remote village (population of 400 at Zozila Pass (near Amarnath) was to station an ANM during the snow fall isolation period of five months, the clear perception even from the citizens in the remotest Indian villages.
  • Full complement in remote area of Kashmir - ANM + 2nd ANM

Status of human resources for health in India -Thamma Rao Status of human resources for health in India -Thamma Rao Presentation Transcript

  • Bangalore 10 Dec. 2010
    Health System Goals
    • Improve Health Care Accessibility
    • Reduce Health Inequalities
    • Be Responsive to User’s Needs
    Human Resources for HealthDr. D. Thamma RaoAdvisor - Public Health (Human Resources)National Health Systems Resources Centre, NRHMNew Delhi
    HRH is the Critical Factor
    For Health Care Accessibility - Equity - Quality
  • Health Sector Planning & H R H Development
    1946Bhore - Every Citizen to Secure Adequate Health Care
    1961Mudaliar “ - Infrastructure Development & Cadres at Primary level
    1963Chaddha “ - Health Worker /10000 Pop. M&F & PHC - Lab Asst., FP Worker
    1966Mukerjee “ - Review of Staff Pattern for Fly Planning, NMED etc
    1967Jungal “ - United Cadre, Org. & HR Integration
    1974Kartarsingh“ - M P W Concept for Fly Planning
    1975Srivastava “ - Medical Education & Support Manpower
    Cadre of Health Assistants, VHG ….
    Training Curriculum - MPHWS, HA & LHV
    1983Bajaj “ - Essential Educational Infrastructure, Carrer Prospects ..
    2000GoI - National Population Policy - Decentralised Planning
    “ - N R H M
    2007 “ - Task Force Report -Planning for HRH (Planning Commission)
  • Human Resources for Health
    H R H - Norms
    H R H
    Providers - Professional, Technicians, Auxillaries , PH specialists …
    Managerial & Supportive - Policy makers, Administrators, Statisticians, Researchers …
    HRH are not just individuals but integral part of TEAMS – each one Contributing different Skills and Performing different functions
    HRH determines - What Service, When, Where, What extent, priority…
    Of Late, We are witnessing Growing Challenges to maintain required numbers, distribution & quality to meet the changing health care needs
  • H R H Diversity
    • Rigorously trained Specialists & Super-specialists
    • General Duty Doctors - Allopathy, AYUSH, Dentists
    • Physiotherapists, Occupational therapists, Speech therapists..
    • Nurses - General, O Ts, ICCUs, ICMUs, IRCUs, Post- Operative,
    • Paramedics - Pharmacists, Radiographers, Optometricians, Counsilors, Medical Social Workers ……
    • Technicians – Laboratory (Pathology, Microbiology, Biochemistry) OT, ECG, EEG, EMG, USG, CT, MRI, RT, NMT, Audiometry, …
    • Dressers, Nursing orderlies, OT Attendrs, Stretcher Bearers…
    Drivers, Cleaners, Cooks, Clerical Staff, Managers
    • Informal HR – TBA, Bone setters, Traditional healers...
  • Invisible H R H - Preventive Health Care
    • ANM (Auxillary Nurse Midwife) & Health Worker (Male)
    • Lady Health Visitor & Health Assistant (Male)
    • Public Health Nurse & Health Inspector
    • Paramedical Worker & Non-Medical Supervisor
    • Insect Collectors & Entomologists
    • Cold chain mechanics & Cold Chain Officers
    • Food Inspectors & Drug Inspectors
    • Deputy C M H O & D C M H O
    • Health Programme Managers – District & State Levels
  • Health System’s Vital Ingredient - H R H
    Numerical Adequacy
    Workforce Management
    Workforce Performance
    Capacity Building
    Skill Mix
  • HRH in India
    HRH in India (%) - Census 2001
    National Health Profile, MOHFW, Govt. of India 2009
    Total 21,68,223
    Doctors(Allopathy) 31 %
    Physicians (AYUSH) 9 %
    Dentists 22962 1 %
    Nurses 25 %
    Midwives 13 %
    Pharmacists 11%
    Other HW, 155177, 7%
    Traditional HWs, 51318, 3%
  • H R H - Density (Per 10,000 Population)
    World Health Statistics 2007- WHO
  • NRHM - HR Vision & Achievements 2009 (for Existing Health Centres)
    2007 March 2009 Target 2012
  • Primary Health Care Facilities - Growth
  • H R H Requirements (as per IPHS norms for year 2011)
  • H R H Availability & Health Care Outcomes (DLHS-3)
  • HRH Density & Health Care Outcomes
    NB: DLHS -3 Children 12-35 months
  • Inequities within the States
    Full vaccination in Children - Low & High performing districts in states DLHS -3
    Equitable Distribution & Quality - Essential for health care provision
  • HR - Quality & Accountability – Consumer’s Perceptions (DLHS-3)
  • Health inequities across States, Districts & Social Groups
    Total Prioritised
    • Institutional Deliveries (< 80%) - 485216
    • Full Immunisation in Children(<85%) - 358 177
    • TB Control (NSPCDR of < 60 %) - 243 99
    • Malaria(API >1.9) or Kala-azar cases - 200 102
    • Leprosy (PR >1.0) – 53 53
  • Health Care Challenges Across States
  • National Rural Health Mission
    Health Policy Planning & Implementation
    Architectural Correction of Health Systems
    Bottom-up Planning Approach
    Need Based Planning
    Provision of Essential H R H & Infrastructure - Service Guarantees as per IPHS
    - Contractual Staff (2nd ANM, Nurses, LT ...Drs.)
    - ASHAs
    Convergence of all Vertical Programmes
  • Vision – National Rural Health Mission (India)
    SDH / CHC
    120,000 population
    SDH – Sub District Hospital
    CHC - Community Health Centre
    PHC - Primary Health Centre
    SHC – Sub Health Centre
    LHV – Lady Health Visitor
    AWW - AnganWadi Worker
    P H C
    30-40 Villages 30,000 Population
    3 Nurses + LHV + Pharmacist +
    Lab. Tech. + MOs (Allopath)+MO (AYUSH)
    S H C
    5 -6 Villages 5000 Population
    Auxiliary Nurse Midwives (Regular + Contractual)
    & Health Worker (Male)
    Community Level (Village) 1,000 Population
    ASHA (Accredited Social Health Activiist) + AWW (ICDS)
  • NRHM Achievements 2007-2010
    Infrastructure up-gradation of - 28,686 SHCs,
    5,407 PHCs,
    4,937 Block PHCs
    444 Dist. Hosp.
    Additional Human Resource provided in Govt. sector
    Over 8,20,000 ASHAs,
    48,104 ANMs,
    3,295 Pharmacists,
    26,253 Nurses,
    8,782 Doctors,
    2,474 Specialists ..
  • Performance of IPHS Institutions
  • Priyadarshini FBNC,Jaipur
  • HRH Thrust of NRHM in India
    • Bridge the gaps between HRH Availability and
    Unmet Needs of the Community
    • Increase HRH in Rural Areas.
    • Provision of essential HRH, Infrastructure &
    Service Guarantees - Indian Public Health Standards
    • HRH Skill Up gradation for ensuring services
    • Eliminate quackery in the Villages
    • Supportive Supervision of HRH
  • HRH initiatives in India
    • New Cadre of Rural Practioners for Hilly/ tribal areas
    - Bachelor of Rural Medical Practioners course 3 ½ years
    - Diploma in Medicine & Rural Health Care –
    Assam State Rural Health Regulatory Act in 2004
    • Enhancement of MBBS seats in Medical Colleges
    150 to 250 per year
    • Doubling of PG Medical Seats (Specialist Doctors)
    • Central Government Support for new institutes
    Midwifery & Nursing - increased from 1,646 to 5,222
    (2005-06 to 2010-11)
    • Exclusive Council for HRH Educational Institutions
  • H R H Performance
    Human Resource Inputs
    H R objectives
    Health Care Outcomes
    • Numeric adequacy
    • Social outreach
    Equitable Access
    • Systems Support
    • Work environment
    • Remuneration
    • Appropriate skills
    • Training
    • Leadership
  • Provision of Incentives
    Difficult area incentive :Assam, Andhra Pradesh, Jharkhand, Uttarakhand, Bihar, J&K, Madhya Pradesh, Haryana, Himachal Pradesh, Karnataka, Kerala, Orissa, Arunachal Pradesh, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura, Gujarat, Punjab, Tamil Nadu.
    Tribal area incentive :Andhra Pradesh, Himachal Pradesh, J&K, Karnataka, Madhya Pradesh, Maharashtra, Nagaland, Rajasthan, Tamil Nadu.
    Conflict area incentive:Andhra Pradesh, Chhattisgarh,
    Jharkhand, Maharashtra, Orissa
  • Quality of MCH Trainings in Nursing & Midwifery Institutions
    ( Bihar, Chattisgarh, Orissa & Uttarakhand )
  • Making the Best Use of Available Limited HRH
    Achievements –
    • Over Burdened Health Workers Stood Up to meet
    Increased Demands
    • Pooling of Resources at District Level
    • Decentralisation of Powers to Districts
    • Incentives for Good Performance
    Constraints –
    • Inadequate Managerial Support & Supervision
    • Indicators for HR & Governance
    • Norms for Accountability
    • Divergent characteristics of Population & Health Workers
    • Conflict of Interests - Private Practice
  • Summary of HR H Issues in the States
  • HR Division or Cell for HR management - With senior level officers with technical & administrative backgrounds.
    Should have the powers to change the HR rules.
    Should review, plan and monitor HR situation
    All India public health / medical / specialist / GDMOs cadres on par with other central services (IAS, IPS,IRS…..) for postings at the district and state levels
    Public health qualification (1-2) years must be made mandatory for PH positions, who will supervise and direct PH programs including primary health care.
    Large hospitals may have professionally qualified hospital managers.
    Policy changes needed – HRH Management
  • HRH Development, Trainings and Deployment
    are in State sector as the Heath Services
    Delivery and Implementation of Programmes
    are by the States / UTs.
    Substantial Policy changes required to improve HRH and this needs high level of Political Advocacy
    Are we ready for that ?
    Dileep IIM Ahmedabad
    Health Systems
  • Population of Indian States & Other CountriesSource : UN Population Prospects 2005 & RGI Population Estimates 2006
  • Thank YOU
    Deeds, Not words shall speak me
    - John Fletcher
    Dr. D. ThammaRao
    Advisor (Public Health)
    New Delhi, India
  • 37
    Key HRH Issues at Health Facilities
    FRUs / PHCs
    Regular anaesthetist and LSAS trained MO avaialable but anaesthesia apparatus unavailable in OTs at the District Hospital.
    Mismatch between EmOC and LSAS trained personnel - .
    Pathologist posted at a facility where no lab is available.
    No partogram used in Laborrooms.
    Poor utilization of services under RI on Wednesday at sub centre.
    Essential drugs, functional toilets, power supply not available.
    Lack of coordination between RegularContractual ANM.
    Contractual ANM unaware of her duties and responsibiities.
    Records (EC register etc) not maintatined.
    Inadequate use/lack of availability and awareness of guidelines for utilization of untied funds.
  • 38
    Key Issues--Training
    Non implementation of CTPs at district level.
    Training institutions needs strengthening of physical infrastructure, development of faculty,
    Lack of training in essential newborn care & treatment/ stabilization of Sick Newborns for the existing MOs/Staff Nurses/ANMs.
    Training on IUD/Minlap/SBA/IMEP/ARSH/ Immunisation particularly for contract staff needs urgent focus.