Bangalore   10 Dec. 2010<br />Health   System  Goals<br /><ul><li>Improve  Health   Care   Accessibility
    Reduce   Health   Inequalities
Be   Responsive  to  User’s   Needs</li></ul>Human  Resources  for  HealthDr.  D.  Thamma  RaoAdvisor  - Public Health  (H...
Health   Sector   Planning    &    H R H   Development  <br />1946Bhore 	 -   Every  Citizen  to   Secure    Adequate  Hea...
Human   Resources  for Health      <br />H R H  -  Norms <br />H R H<br />Providers  -  Professional,   Technicians, Auxil...
       H R H   Diversity   <br /><ul><li>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, Audiomet...
Dressers, Nursing   orderlies, OT Attendrs, Stretcher Bearers…</li></ul>      Drivers,   Cleaners,  Cooks,  Clerical Staff...
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         </li></li></ul><li>Health    System’s   Vital    Ingredie...
HRH   in  India<br />     HRH  in  India  (%)   -  Census 2001<br />National Health Profile, MOHFW, Govt. of India  2009<b...
H  R  H  -   Density (Per 10,000  Population)<br />World  Health  Statistics  2007-   WHO<br />
NRHM  -  HR Vision  &  Achievements  2009 (for Existing Health Centres)<br />2007                       March   2009      ...
Primary  Health   Care Facilities  -  Growth<br />
H R H   Requirements  (as  per IPHS norms  for year 2011)   <br />
H R H Availability  &   Health  Care  Outcomes (DLHS-3)<br />
HRH   Density    &   Health   Care   Outcomes<br />NB:   DLHS -3  Children 12-35 months<br />
Inequities   within   the  States<br />Full vaccination in Children -  Low & High performing districts in states     DLHS ...
HR   -  Quality  &  Accountability – Consumer’s Perceptions  (DLHS-3)<br />
Health  inequities  across  States,  Districts  &  Social  Groups<br />Districts<br />					   Total         Prioritised <b...
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</li></li></ul><li>Health  Care  Challenges   Across   States <br />
National  Rural  Health  Mission<br />Health  Policy Planning   & Implementation<br />  Architectural  Correction  of  Hea...
Vision – National Rural Health Mission (India)<br />SDH / CHC<br />120,000 population<br />SDH  – Sub  District  Hospital ...
NRHM  Achievements   2007-2010<br />Infrastructure up-gradation of -  28,686   SHCs,   <br />							 5,407   PHCs,  <br />...
 Performance of   IPHS  Institutions<br />
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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 &amp; 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 &amp; Accountability can only be ensured based on the demographic &amp; 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 &amp; ASHAs 6.96 lakhs: States filling vacant posts: Incentives - Difficult area / Rural service a preference for PG Availability of Untied Funds improved HR morale &amp; performance
  • States with Good Infrastructure &amp; Higher HRHDeliver Better Health Care. Five year plans ensured progress. Vision of ID Dev. - I &amp; 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 &amp; 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 &amp; 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 &amp; Rs. 7600 /month for extremism areasStaff nurses &amp; LHV – Rs. 8000/ month for rural area, Rs. 9000/month for tribal area &amp; Rs. 9500 /month for extremism area Madhya Pradesh10,000/pm to regular and contractual specialists ( O&amp;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 &amp; 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

    1. 1. Bangalore 10 Dec. 2010<br />Health System Goals<br /><ul><li>Improve Health Care Accessibility
    2. 2. Reduce Health Inequalities
    3. 3. Be Responsive to User’s Needs</li></ul>Human Resources for HealthDr. D. Thamma RaoAdvisor - Public Health (Human Resources)National Health Systems Resources Centre, NRHMNew Delhi<br />HRH is the Critical Factor <br />For Health Care Accessibility - Equity - Quality <br />
    4. 4. Health Sector Planning & H R H Development <br />1946Bhore - Every Citizen to Secure Adequate Health Care<br />Committee<br />1961Mudaliar “ - Infrastructure Development & Cadres at Primary level<br />1963Chaddha “ - Health Worker /10000 Pop. M&F & PHC - Lab Asst., FP Worker<br />1966Mukerjee “ - Review of Staff Pattern for Fly Planning, NMED etc<br />1967Jungal “ - United Cadre, Org. & HR Integration<br />1974Kartarsingh“ - M P W Concept for Fly Planning<br />1975Srivastava “ - Medical Education & Support Manpower<br /> Cadre of Health Assistants, VHG …. <br /> Training Curriculum - MPHWS, HA & LHV <br />1983Bajaj “ - Essential Educational Infrastructure, Carrer Prospects ..<br />2000GoI - National Population Policy - Decentralised Planning<br /> “ - N R H M<br />2007 “ - Task Force Report -Planning for HRH (Planning Commission) <br />
    5. 5. Human Resources for Health <br />H R H - Norms <br />H R H<br />Providers - Professional, Technicians, Auxillaries , PH specialists … <br />Managerial & Supportive - Policy makers, Administrators, Statisticians, Researchers …<br />HRH are not just individuals but integral part of TEAMS – each one Contributing different Skills and Performing different functions<br />HRH determines - What Service, When, Where, What extent, priority… <br />Of Late, We are witnessing Growing Challenges to maintain required numbers, distribution & quality to meet the changing health care needs <br />
    6. 6. H R H Diversity <br /><ul><li>Rigorously trained Specialists & Super-specialists
    7. 7. General Duty Doctors - Allopathy, AYUSH, Dentists
    8. 8. Physiotherapists, Occupational therapists, Speech therapists..
    9. 9. Nurses - General, O Ts, ICCUs, ICMUs, IRCUs, Post- Operative,
    10. 10. Paramedics - Pharmacists, Radiographers, Optometricians, Counsilors, Medical Social Workers ……
    11. 11. Technicians – Laboratory (Pathology, Microbiology, Biochemistry) OT, ECG, EEG, EMG, USG, CT, MRI, RT, NMT, Audiometry, …
    12. 12. Dressers, Nursing orderlies, OT Attendrs, Stretcher Bearers…</li></ul> Drivers, Cleaners, Cooks, Clerical Staff, Managers<br /><ul><li> Informal HR – TBA, Bone setters, Traditional healers... </li></li></ul><li>Invisible H R H - Preventive Health Care<br /><ul><li>ANM (Auxillary Nurse Midwife) & Health Worker (Male)
    13. 13. Lady Health Visitor & Health Assistant (Male)
    14. 14. Public Health Nurse & Health Inspector
    15. 15. Paramedical Worker & Non-Medical Supervisor
    16. 16. Insect Collectors & Entomologists
    17. 17. Cold chain mechanics & Cold Chain Officers
    18. 18. Food Inspectors & Drug Inspectors
    19. 19. Deputy C M H O & D C M H O
    20. 20. Health Programme Managers – District & State Levels </li></li></ul><li>Health System’s Vital Ingredient - H R H <br />Numerical Adequacy <br />Workforce Management <br />Workforce Performance <br />Capacity Building<br />Skill Mix <br />
    21. 21. HRH in India<br /> HRH in India (%) - Census 2001<br />National Health Profile, MOHFW, Govt. of India 2009<br />Total 21,68,223<br />Doctors(Allopathy) 31 %<br />676756<br />Physicians (AYUSH) 9 %<br />196488<br />Dentists 22962 1 %<br />Nurses 25 % <br /> 545933<br />Midwives 13 % <br />277655<br />Pharmacists 11%<br />239276<br />Other HW, 155177, 7%<br />2009<br />2009<br />2009<br />2009<br />Traditional HWs, 51318, 3%<br />
    22. 22. H R H - Density (Per 10,000 Population)<br />World Health Statistics 2007- WHO<br />
    23. 23. NRHM - HR Vision & Achievements 2009 (for Existing Health Centres)<br />2007 March 2009 Target 2012<br />
    24. 24. Primary Health Care Facilities - Growth<br />
    25. 25. H R H Requirements (as per IPHS norms for year 2011) <br />
    26. 26. H R H Availability & Health Care Outcomes (DLHS-3)<br />
    27. 27. HRH Density & Health Care Outcomes<br />NB: DLHS -3 Children 12-35 months<br />
    28. 28. Inequities within the States<br />Full vaccination in Children - Low & High performing districts in states DLHS -3 <br />D<br />Equitable Distribution & Quality - Essential for health care provision<br />
    29. 29. HR - Quality & Accountability – Consumer’s Perceptions (DLHS-3)<br />
    30. 30. Health inequities across States, Districts & Social Groups<br />Districts<br /> Total Prioritised <br /><ul><li>Institutional Deliveries (< 80%) - 485216
    31. 31. Full Immunisation in Children(<85%) - 358 177
    32. 32. TB Control (NSPCDR of < 60 %) - 243 99
    33. 33. Malaria(API >1.9) or Kala-azar cases - 200 102
    34. 34. Leprosy (PR >1.0) – 53 53</li></li></ul><li>Health Care Challenges Across States <br />
    35. 35. National Rural Health Mission<br />Health Policy Planning & Implementation<br /> Architectural Correction of Health Systems<br />Bottom-up Planning Approach <br />Need Based Planning <br /> Provision of Essential H R H & Infrastructure - Service Guarantees as per IPHS<br />- Contractual Staff (2nd ANM, Nurses, LT ...Drs.)<br /> - ASHAs<br />Convergence of all Vertical Programmes<br />
    36. 36. Vision – National Rural Health Mission (India)<br />SDH / CHC<br />120,000 population<br />SDH – Sub District Hospital <br />CHC - Community Health Centre<br />PHC - Primary Health Centre<br />SHC – Sub Health Centre<br />LHV – Lady Health Visitor<br />AWW - AnganWadi Worker<br />Nurses, <br />MOs,<br />SpecialistsObst./Anaest./Pedia/Med/Sur<br />P H C<br />30-40 Villages 30,000 Population<br />3 Nurses + LHV + Pharmacist + <br />Lab. Tech. + MOs (Allopath)+MO (AYUSH) <br />S H C<br />5 -6 Villages 5000 Population<br />Auxiliary Nurse Midwives (Regular + Contractual) <br />& Health Worker (Male) <br />Community Level (Village) 1,000 Population<br />ASHA (Accredited Social Health Activiist) + AWW (ICDS)<br />
    37. 37. NRHM Achievements 2007-2010<br />Infrastructure up-gradation of - 28,686 SHCs, <br /> 5,407 PHCs, <br /> 4,937 Block PHCs <br /> 444 Dist. Hosp.<br />Additional Human Resource provided in Govt. sector<br />Over 8,20,000 ASHAs, <br /> 48,104 ANMs, <br /> 3,295 Pharmacists,<br /> 26,253 Nurses, <br /> 8,782 Doctors, <br /> 2,474 Specialists ..<br />
    38. 38. Performance of IPHS Institutions<br />
    39. 39. BANKURA<br />
    40. 40. Priyadarshini FBNC,Jaipur<br />
    41. 41. HRH Thrust of NRHM in India<br /><ul><li> Bridge the gaps between HRH Availability and</li></ul> Unmet Needs of the Community<br /><ul><li> Increase HRH in Rural Areas.
    42. 42. Provision of essential HRH, Infrastructure &</li></ul> Service Guarantees - Indian Public Health Standards <br /><ul><li> HRH Skill Up gradation for ensuring services
    43. 43. Eliminate quackery in the Villages
    44. 44. Supportive Supervision of HRH </li></li></ul><li>HRH initiatives in India<br /><ul><li> New Cadre of Rural Practioners for Hilly/ tribal areas</li></ul> - Bachelor of Rural Medical Practioners course 3 ½ years<br /> - Diploma in Medicine & Rural Health Care – <br /> Assam State Rural Health Regulatory Act in 2004<br /><ul><li> Enhancement of MBBS seats in Medical Colleges</li></ul> 150 to 250 per year<br /><ul><li> Doubling of PG Medical Seats (Specialist Doctors)
    45. 45. Central Government Support for new institutes</li></ul>Midwifery & Nursing - increased from 1,646 to 5,222<br /> (2005-06 to 2010-11) <br /><ul><li>Exclusive Council for HRH Educational Institutions </li></li></ul><li>H R H Performance<br />Human Resource Inputs<br />H R objectives<br />Performance<br />Health Care Outcomes <br /><ul><li>Numeric adequacy
    46. 46. Social outreach</li></ul>Coverage<br />Equitable Access<br /><ul><li> Systems Support
    47. 47. Work environment
    48. 48. Remuneration</li></ul>Motivation<br />Healthy <br /> INDIA<br />Efficiency<br /><ul><li>Appropriate skills
    49. 49. Training
    50. 50. Leadership</li></ul>Quality<br />Competence<br />
    51. 51. Provision of Incentives<br />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.<br />Tribal area incentive :Andhra Pradesh, Himachal Pradesh, J&K, Karnataka, Madhya Pradesh, Maharashtra, Nagaland, Rajasthan, Tamil Nadu.<br />Conflict area incentive:Andhra Pradesh, Chhattisgarh,<br /> Jharkhand, Maharashtra, Orissa <br />
    52. 52. Quality of MCH Trainings in Nursing & Midwifery Institutions <br />( Bihar, Chattisgarh, Orissa & Uttarakhand )<br />
    53. 53. Making the Best Use of Available Limited HRH<br />Achievements –<br /><ul><li> Over Burdened Health Workers Stood Up to meet</li></ul> Increased Demands<br /><ul><li> Pooling of Resources at District Level
    54. 54. Decentralisation of Powers to Districts
    55. 55. Incentives for Good Performance</li></ul>Constraints –<br /><ul><li> Inadequate Managerial Support & Supervision
    56. 56. Indicators for HR & Governance
    57. 57. Norms for Accountability
    58. 58. Divergent characteristics of Population & Health Workers
    59. 59. Conflict of Interests - Private Practice</li></li></ul><li>Summary of HR H Issues in the States <br />
    60. 60. HR Division or Cell for HR management - With senior level officers with technical & administrative backgrounds.<br />Should have the powers to change the HR rules.<br />Should review, plan and monitor HR situation<br />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<br />Public health qualification (1-2) years must be made mandatory for PH positions, who will supervise and direct PH programs including primary health care. <br />Large hospitals may have professionally qualified hospital managers.<br />31<br />Policy changes needed – HRH Management<br />
    61. 61. HRH Development, Trainings and Deployment<br /> are in State sector as the Heath Services<br /> Delivery and Implementation of Programmes<br /> are by the States / UTs.<br />Substantial Policy changes required to improve HRH and this needs high level of Political Advocacy<br />Are we ready for that ? <br />Dileep IIM Ahmedabad<br />32<br />Health Systems <br />
    62. 62. Population of Indian States & Other CountriesSource : UN Population Prospects 2005 & RGI Population Estimates 2006<br />
    63. 63.
    64. 64.
    65. 65. Thank YOU<br />Deeds, Not words shall speak me<br /> - John Fletcher<br />Dr. D. ThammaRao<br />Advisor (Public Health)<br />New Delhi, India<br />thammarao@gmail.com<br />
    66. 66. 37<br />Key HRH Issues at Health Facilities<br /> FRUs / PHCs<br />Regular anaesthetist and LSAS trained MO avaialable but anaesthesia apparatus unavailable in OTs at the District Hospital.<br />Mismatch between EmOC and LSAS trained personnel - .<br />Pathologist posted at a facility where no lab is available. <br />No partogram used in Laborrooms.<br /> SHCs<br />Poor utilization of services under RI on Wednesday at sub centre. <br />Essential drugs, functional toilets, power supply not available. <br />Lack of coordination between RegularContractual ANM. <br />Contractual ANM unaware of her duties and responsibiities.<br />Records (EC register etc) not maintatined. <br />Inadequate use/lack of availability and awareness of guidelines for utilization of untied funds.<br />
    67. 67. 38<br />Key Issues--Training<br />Non implementation of CTPs at district level. <br />Training institutions needs strengthening of physical infrastructure, development of faculty,<br />Lack of training in essential newborn care & treatment/ stabilization of Sick Newborns for the existing MOs/Staff Nurses/ANMs.<br />Training on IUD/Minlap/SBA/IMEP/ARSH/ Immunisation particularly for contract staff needs urgent focus. <br />
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