Human Resources for Health
Dr. D. Thamma RaoAdvisor - Public Health (Human Resources)
National Health Systems Resources Centre, NRHMNew Delhi
Bangalore 10 Dec. 2010 Health System Goals• Improve Health Care Accessibility• Reduce Health Inequalities• Be Responsive to User’s Needs
HRH is the Critical Factor For Health Care Accessibility - Equity -
Quality
Health Sector Planning & H R H Development
1946 Bhore - Every Citizen to Secure Adequate Health Care
Committee
1961 Mudaliar “ - Infrastructure Development & Cadres at Primary level
1963 Chaddha “ - Health Worker /10000 Pop. M&F & PHC - Lab Asst., FP Worker
1966 Mukerjee “ - Review of Staff Pattern for Fly Planning, NMED etc
1967 Jungal “ - United Cadre, Org. & HR Integration
1974 Kartarsingh“ - M P W Concept for Fly Planning
1975 Srivastava “ - Medical Education & Support Manpower
Cadre of Health Assistants, VHG ….
Training Curriculum - MPHWS, HA & LHV
1983 Bajaj “ - Essential Educational Infrastructure, Carrer Prospects ..
2000 GoI - National Population Policy - Decentralised Planning
2005 “ - N R H M
2007 “ - Task Force Report -Planning for HRH (Planning Commission)
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
Human Resources for Health
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
Workforce Management
Numerical Adequacy
Workforce Performance
Capacity Building
Skill Mix
Health System’s Vital Ingredient - H R H
HRH in India (%) - Census 2001
Traditional HWs, 51318, 3%
Pharmacists 11%239276
Midwives 13 % 277655
Nurses 25 % 545933
Dentists 22962 1 %
Total 21,68,223
Other HW, 155177, 7%
Doctors (Allopathy) 31 % 676756
Physicians (AYUSH) 9 % 196488
0
2500
5000
7500
10000
757377
1043363
608788
681692
Doctors
Nurses
MidwivesPharmacists
2009 2009 2009 2009
National Health Profile, MOHFW, Govt. of India 2009
HRH in India
H R H - Density (Per 10,000 Population) World Health Statistics 2007- WHO
DoctorsNurses &Midwives
Pharmacists Lab. Tech.
Other HRH
India 0.6 1.3 0.6 0.02 1.13
China
1.6 1.03 0.3 0.16 0.93
Cuba 5.9 7.4 - 0.07 2.75
U S A 5.5 7.7 0.7 2.30 16.1
U K 1.7 5.6 0.6 0.34 3.79
Specialists at CHC 3 Doctors at PHC 3 Nurses at PHC 2nd ANMs at SHCs0
20000
40000
60000
80000
100000
120000
140000
160000
3550
2030817371
5789
3138123982
34290
25079
67110 67110
145272
NRHM - HR Vision & Achievements 2009 (for Existing Health Centres)
2007 March 2009 Target 2012
1951 1961 1971 1981 1991 2001 2007
217 2071 3043 4,510725 25655,112 5740
20450 22842 23,39128,489
51,405
1,30,9581,37,311
1,45,894
CHC
PHC
SHC
2009
Primary Health Care Facilities - Growth
H R H Requirements (as per IPHS norms for year 2011)
CategoryHRH for
Existing SHC, PHC & CHC
HRH forSHC, PHC & CHC as per IPHS
Required 2009
Short fall2009
Required2011
Short fall 2011
1 Doctors (Allopathy) 53,354 28,356 2,00,607 1,75,609
2 Nurses 67,651 10,676 3,00,910 2,43,935
3 A N M s 2,91,788 1,00,869 5,54,276 3,63,357
4 Pharmacists 60,312 39,345 1,22,593 1,01,626
5 Lab. Technician 60,312 47,408 1,22,593 1,09,689
Total 5,33,417 2,26,654 13,00,979 9,94,216
H R H Availability & Health Care Outcomes (DLHS-3)
Uttar P
rades
hM
P
Bihar
Rajas
than
Jhar
khand
Chhattis
garh
Orissa A P
Karnat
aka
Wes
t Ben
gal
Tamiln
adu
Pondich
erry
Kerala
Goa
0
10
20
30
40
50
60
70
80
90
100
1316
1014 14
1620 21 21
24 23
54
3842
30
36
41
49
54
59 62
67
77 76
8380 80
90
72 72
58
65
48
59
71
54
47
3735
25
13 13
HRH Child Immunisation (1-2 yrs) DLHS-3 IMR SRS
States
Population Quality perceived
to be GOOD
Health Worker Density (/10000 Popu.–
Census 2001)
Health Care Out-Comes
MMR
IMR
NFHS - 3 (2005-06)
DLHS- 3 (07-08)
SRS (04-06)
SRS (04-06)
(Lakhs)
Per Bed
DLHS-3 (07-
08) HRH(all)
Doctor Allopathy
Nurse &
ANM
ANC (min.3
)
Deliveries
by HRH
Full
Immunisation
Children S R S S R S
India 2,315 19.5 6.1 7.4 52 47 44 54 254 55
1 U P190
35,646 35 13 6 3 27 27
23
30 440 69
2 Bihar 936 4,163 16 10 4 3 17 2933
41 312 58
3 Rajasthan 645 1,977 37 14 4 5 41 4127
49 388 65
4 M P 687 3,392 37 16 5 6 41 3340
36 335 72
5 Jharkhand 302 5,494 44 14 4 6 36 2834
54 312 48
6 Orissa 397 2,724 61 20 3 13 62 4452
62 303 71
7 A P 824 2,351 37 21 8 8 85 75 46 67 154 54
8Karnatak
a 576 1,163 49 21 7 8 80 70 55 77 213 47
9West
Bengal 870 1,734 49 24 7 6 62 48 64 76 141 37
10Tamil Nadu
661 1,391 45 23 6 10 96 91 81 83 111 35
11Pondicher
ry 12 352 73 54 11 29 98 99 89 80 20 25
12 Kerala 338 1,217 66 38 6 19 94 99 75 80 95 13
NB: DLHS -3 Children 12-35 months
HRH Density & Health Care Outcomes
Full vaccination in Children - Low & High performing districts in states DLHS -3
State Average Lowest Highest Difference HRH
1 Bihar 41Jamui 17 Kaimur
22Muzaffarpur 57 Saran
65 48 10
2 UP 30 Budaun 11 Etah
12
Pratapgarh 59 Deoria
7261 13
3 Rajasthan
49Alwar 27 S.Madhopur
29Banaswara 87 Dungarpur
88 59 14
4 Jharkhand
54Girdih 22 Godda
28Lohardaga 81 E. Singh
Bhumi 82 60 14
5 MP 36Damoh 11 Tikargarh
14
Ujjain 74 Balaghat
7564 16
6 Orissa 62Rayagada 27 Malkangiri
35
Jajapur 82 Baleshwar
8356 20
7 Karnataka
77Raichur 50 Bijapur
51Kolar 95 Kodagu
96 46 21
8 A P 67Srikakulam52 Nellore
53Rangareddy 81 Karimnagar
82 30 21
9West Bengal
76 U.Dinajpur 55 Murshidabad62
Bankura 92 Hugli 93 38 24
10 Tamil Nadu
83Madurai 60 Theni
61Viluppuram 95 Nagpattinam
95 35 23
11 Kerala 80Malapuram62 Palakkad
65Alappuzha 92 Thiruvnthpuram 93 31 38
D
Inequities within the States
Equitable Distribution & Quality - Essential for health care provision
U PM
P
Bihar
Rajasth
an
Jharkhand
Chhattisg
arh
Oris
sa A P
Karn
ataka
Wes
t Ben
gal
Tamiln
adu
Pondicher
ry
Ker
ala
Goa
0
20
40
60
80
100
120
35 37
16
37
4449
61
37
49 4945
73
6671
1316
1014 14 16
20 21 2124 23
54
3842
92 92
79
9390
94 9287 86
96 97100
85
96
Good Quality HRH Personnel Available
HR - Quality & Accountability – Consumer’s Perceptions (DLHS-3)
Districts
Total Prioritised
Institutional Deliveries (< 80%) - 485 216
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 inequities across States, Districts & Social Groups
Health Care Challenges Across States
Challenge States
1 TB Cases - HighAndhraPradesh, Assam, Bihar, Gujarat, Jharkhand, Tamilnadu, West Bengal & U.P.
2 Malaria - HighAP, Arunachal, Assam, Bihar, Chattisgarh, Jharkhand, Karnataka, Maharashtra, Meghalaya, M.P, Orissa, Rajasthan, West Bengal & U.P.
3 DiabetesDeli, Goa, Kerala, Tamilnadu, Tripura & West Bengal
4Immunisation Full in Children
Bihar, Jharkhand, M.P, Rajasthan & U.P.
5Children < 3 Yrs Under Weight
Assam, Bihar, Chattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Maharashtra, M.P, Orissa, Rajasthan, West Bengal & U.P.
6 Infant Mortality Assam, Bihar, Chattisgarh, M.P, Orissa, Rajasthan& U.P.
7 Maternal Mortality
Assam, Bihar, M.P, Orissa, Rajasthan & U.P.
8 High Fertility Rate
Bihar, Chattisgarh, Jharkhand, M.P, Rajasthan & U.P.
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
National Rural Health Mission
SDH / CHC
120,000 populatio
nNurses, MOs,
Specialists
Obst./Anaest./Pedia/Med/SurP 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)
Vision – National Rural Health Mission (India)
SDH – Sub District Hospital CHC - Community Health CentrePHC - Primary Health CentreSHC – Sub Health CentreLHV – Lady Health VisitorAWW - AnganWadi Worker
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. sectorOver 8,20,000 ASHAs,
48,104 ANMs, 3,295 Pharmacists,
26,253 Nurses, 8,782 Doctors, 2,474 Specialists ..
Indicator
Performance
Progress2007-08 2008-09
1 Out Patients 1,21,37,284 1,49,63,492 23 %
2 In-Patients 14,41,845 19,62,679 36 %
3 Deliveries 1,84,367 3,12,354 69 %
4 MTPs 14,546 11,932 18 %
5 Operations - Major 1,02,852 1,53,298 49 %
6 Operations - Minor 1,45,832 1,84,298 26 %
Performance of IPHS Institutions
BANKURA
Priyadarshini FBNC,Jaipur
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 Thrust of NRHM 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
HRH initiatives in India
• Appropriate
skills
• Training
• Leadership
• Systems
Support
• Work
environment
• Remuneration
• Numeric
adequacy
• Social outreach
Human Resource Inputs
Competence
Coverage
H R objectiv
es
Quality
Equitable Access
Health Care Outcomes
Performance
Motivation
Healthy INDIA
Efficiency
H R H Performance
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
Provision of Incentives
Skill
ANM Schools (n=24, 36 & 61)
Nursing Schools (n=25, 30 & 67)
Nursing College B.Sc. (n=49 & 27)
Independently Independently Independently
Bihar
Chattisgarh
Orissa
Uttarakhand
Bihar
Chattisgarh
Orissa
Chattisgarh
Orissa
Uttarakhand
Child care
Immunisation 8 25 25 9 15 17 30 24 15 2
New Born Resuscitation
6 21 18 0 13 0 23 17 9 0
Maternal care
Conducting Delivery 6 13 12 5 18 13 20 3 12 0
Ante Natal Care 8 17 23 14 20 24 32 25 11 5
Post Natal care 11 29 24 19 18 27 39 41 16 3
Family Welfare
IUD Insertion 5 0 25 5 13 0 21 5 14 1
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
Buildings and equipments made available and HRH left out..
Distributional imbalances - geographic, institutional and occupations
Qualitative imbalances - mismatches, under-qualification etc
Sanctioned Posts are < Requirements for Existing Health Facilities
Vacancies in Sanctioned Posts - Adhoc Contractual Appointments
Lack of H R H Mgt. Inf. Systems & Mechanisms for HR Planning Inadequate Managerial Support & Supervision of H R H
Lack of Accountability & Short-falls in Managerial Skills
Inadequacies in Training Capacities & Wastages
Lack of medical/ nursing/ paramedical institutions to generate additional H R H HRH Losses - Poor Working Conditions & Low Pay
Non- implementation of fair Postings & Transfers, Career Paths, Incentives, NPA
31
• 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
32
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
Dr. D. Thamma Rao Advisor (Public
Health)New Delhi, India
Deeds, Not words shall speak me
- John Fletcher
37
Key HRH Issues at Health Facilities
FRUs / PHCsRegular 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 Labor rooms. SHCsPoor utilization of services under RI on Wednesday at sub
centre. Essential drugs, functional toilets, power supply not
available. Lack of coordination between Regular\Contractual 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--TrainingNon 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.