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Status of human resources for health in India -Thamma Rao
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2. Reduce Health Inequalities
3. Be Responsive to User’s NeedsHuman 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
4. Health Sector Planning & H R H Development 1946Bhore - Every Citizen to Secure Adequate Health Care Committee 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)
5. 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
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7. General Duty Doctors - Allopathy, AYUSH, Dentists
21. HRH in India HRH in India (%) - Census 2001 National Health Profile, MOHFW, Govt. of India 2009 Total 21,68,223 Doctors(Allopathy) 31 % 676756 Physicians (AYUSH) 9 % 196488 Dentists 22962 1 % Nurses 25 % 545933 Midwives 13 % 277655 Pharmacists 11% 239276 Other HW, 155177, 7% 2009 2009 2009 2009 Traditional HWs, 51318, 3%
22. H R H - Density (Per 10,000 Population) World Health Statistics 2007- WHO
23. NRHM - HR Vision & Achievements 2009 (for Existing Health Centres) 2007 March 2009 Target 2012
25. H R H Requirements (as per IPHS norms for year 2011)
26. H R H Availability & Health Care Outcomes (DLHS-3)
27. HRH Density & Health Care Outcomes NB: DLHS -3 Children 12-35 months
28. Inequities within the States Full vaccination in Children - Low & High performing districts in states DLHS -3 D Equitable Distribution & Quality - Essential for health care provision
35. 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
36. 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 Nurses, MOs, SpecialistsObst./Anaest./Pedia/Med/Sur 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)
37. 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 ..
58. Divergent characteristics of Population & Health Workers
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60. 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. 31 Policy changes needed – HRH Management
61. 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 32 Health Systems
62. Population of Indian States & Other CountriesSource : UN Population Prospects 2005 & RGI Population Estimates 2006
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65. Thank YOU Deeds, Not words shall speak me - John Fletcher Dr. D. ThammaRao Advisor (Public Health) New Delhi, India thammarao@gmail.com
66. 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. SHCs Poor utilization of services under RI on Wednesday at sub centre. Essential drugs, functional toilets, power supply not available. Lack of coordination between Regularontractual 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.
67. 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.
Editor's Notes
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
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