Health Labour Market Analysis: CHHATTISGARH

Jointly prepared by WHO and State Health Resource Centre, Chhattisgarh for the Department of Health and Family Welfare, Chhattisgarh

January 2020 Health Labour Market Analysis: CHHATTISGARH – Policy Brief

ISBN: 978-92-9022-782-3

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Printed in India Health Workforce for Universal Health Coverage in Chhattisgarh - A Policy Brief

To meet the health workforce requirements for the successful achievement Universal Health Coverage (UHC) in the state of Chhattisgarh a Health Labour Market Analysis (HLMA) was conducted as a collaboration between the Department of Health and Family Welfare and Medical Education, the State Health Resource Center, Chhattisgarh, and the World Health Organization. The HLMA is a policy informing document providing insight into key health workforce bottlenecks and opportunities in the state. The central aim of the HLMA was to develop policy recommendations regarding the health workforce in the state to enable progress towards the achievement of UHC.

Through a process of stakeholder engagement two key questions relating the human resources for health in the state were identified: 1. Is the production of health workers (with a focus on specialists, medical officers and nurses) in Chhattisgarh sufficient to meet current demand and how can the recruitment and deployment be improved? 2. What are the key health workforce elements to consider for a successful rolling out of the Health and Wellness Centers in Chhattisgarh?

Assessing the Demand for Medical Oﬃcers – How many more doctors does Chhattisgarh need? The total number of doctors in Chhattisgarh is estimated to be around 8,500 including both public and private sector. This translates into approximately 3 doctors per 10,000 population far below the national average of approximately 8 doctors per 10,000 population.

In Chhattisgarh, approximately 3,800 doctors are working in the public sector, around half of them are Specialists, which is around 45% of total doctors working in the state. This proportion is better than the national average.

Number of Government Doctors (including specialists) in Chhattisgarh

Number of Government PGs & non-PGs allopathic Doctors

2500 1961 2000 1836

1500 1186 1000 900 431 500 300 180 95 100 200 105 150 150 0 Doctors under Doctors with Doctors under Doctors Doctors in Doctors in Total in Public DHS (regular PG DME working in AIIMS Hospitals Sector + Contractual) qualiﬁcations DHS under 2- owned by working under Year Bond for Public Sector DHS MBBS and Units PG Education (Industrial Organisations owned by Central Government) Specialist Doc tors (with PG) MBBS Doctors (without PG)

Source of Data: Data collected from DHS, DME and AIIMS

1 However, while the number of approved posts has increased recently, the number of medical oﬃcers holding position in the public sector did not keep pace untill 2018. The situation has improved marginally in 2019 with recruitment of 239 new MOs.

Gap Between approved posts and working MOs 2500

2000

1500

1000

500

0 2016 2017 2018

Approved Posts Working

The number of vacant posts of regular MOs under DHS is signiﬁcant especially in peripheral areas, reaching more than 70% in 5 districts.

VACANCY OF MEDICAL OFFICERS IN CHHATTISGARH

47% 85% 73% Balrampur koriya Surajpur

4% Surguja 49% Jashpur Korba 29% 19% 44% 50% Raigarh 49% Mungeli Bilaspur Kabirdham 61% Janjgir-Champa 58% Bemetara 53% Baloda Bazar

21% 0% Mahasamund Durg Raipur Rajnandgaon 25% 42% 51% 38% Balod Dhamtari 35% Gariyaband 46% Kanker

Kondagaon Narayanpur 64% 80%

Date Layers Bastar Bijapur 46% Medical Officer. 0% - 25% 79% Dantewada Medical Officer. 26% - 50% 68% Medical Officer. 51% - 75% Medical Officer. >75% Sukma 79%

2 The presence of private doctors is also highly skewed with a large proportion being in bigger urban areas. The state currently needs to recruit around 1200 more MOs to meet its existing needs of the government healthcare facilities.

Is the production of medical oﬃcers in Chhattisgarh suﬃcient to meet current demand?

Annual Intake of Medical Students 800

700

600

500

400

300

200

100

0 1995 2000 2005 2010 2015 2020

The annual intake of medical students rose from ﬁvefold between 2003 and 2019. Resulting in 2.59 medical graduate per 100,000 population in 2019 which although a vast improvement still sits below the national ﬁgure of 5.19 per 100,000 population.

Has the increase in supply resulted in an increased availability of medical oﬃcers working with government?

There is a clear absorption capacity issue: over the past two decades the state has produced around 4,000 MBBS doctors, but only around 900 regular MOs have been recruited. Therefore, attracting and recruiting appears as a major challenge for the absorption of medical oﬃcers in the health labour market. The age proﬁle of existing regular MOs shows that the recruitments have been inadequate.

Table- Age distribution of regular Medical Oﬃcers 1 Under 30 years 12 (1%) 2 31- 40 years 260 (22%) 3 41-50 years 037 (26%) 4 51-60 years 389 (33%) 5 Above 60 years 200 (17%) 6 Age not mentioned 12 (1%)

Total 1180 7 Source of Data: Data collected from DHS Age category Percentage

The recruitment drives have not been regular with gap of two to three years in successive drives. The success rate in attracting MOs has improved to some extent as seen in the last recruitment drive.

3 Table- Recruitment drives conducted for Medical Oﬃcers in last 5 Years Year of No. of Medical % Recruited No. of posts Recruitment Recruitment Agency oﬃcers against advertised drive recruited Advertised 2014 Health Department 709 128 18%

2016 Health Department 616 214 35%

2019 Health Department 423 239 57%

Source of Data: Data collected from DHS

The key concern, that continues to persist in the recent recruitment drives also, is of inability to attract MOs to ﬁll the vacancies in rural and remote areas.

Is the production of specialists in Chhattisgarh suﬃcient to meet current demand and how can recruitment and deployment process be improved?

There are estimated 3,461 specialists in the state, similar to the the number of medical oﬃcers. A serious shortage of specialists in the public sector is observed throughout the state, especially in District Hospitals and CHCs. The state needs to recruit around 1600 more specialists for ﬁlling vacancies in DHS and DME.

This shortage is largely attributable to the inability of the system to recruit eﬃciently and attract specialists especially in remote and rural areas. As a result, over time the number of specialists (regular) working in Chhattisgarh declined whereas the number of approved posts increased, and this despite an increase in the number of PG seats in medical colleges in the state.

Gap between approved posts and working specialists (regular) 1800 1593 1600 1395 1395 1400

1200

1000

800

600

400 163 175 132 200

0 2016-17 2017-18 2018-19

Approved Working

One key barrier in the recruitment of specialists in Chhattisgarh is that there is no direct recruitment into medical specialist into regular posts, rather the medical specialist cadre is a promotion. Doctors with PG qualifications are recruited as MOs and after five years of service, they are eligible to be promoted as Specialists. Specialists do not find it attractive to join as MOs and at MO level salaries. Even after promotion as Specialists after 5 years of service, the salary increase is inadequate to be attractive.

4 Policy recommendations to improve the production recruitment and deployment of Medical Oﬃcers and Specialists

Recommendation Policy options Promote diploma/ ● Introducing task shifting from Specialists to MOs in DHs alternative short-training and CHCs. courses and task-shifting ● MOs to be trained in most common surgeries and diagnosis and treatment of common diseases and given permission and incentives to perform these procedures. ● Restart Family Medicine PG diploma course and recognise it as specialisation under DHS ● Start other multi-skilling courses ● Adopt the NHM ﬂexible norms for engaging visiting specialists for Fixed days or surgeries ● Greater use of existing mechanisms like DNB

Improve recruitment ● Direct Recruitments of Specialists in Regular Appointments process. The state needs of DHS by modifying Selection Rules to recruit around 1600 more specialists and 1200 ● Regular recruitment drives (at least 1 annually) more MBBS doctors for ● Campus selection (in and out of state) government sector. ● Interaction with medical students in state during internship ● Better deployment strategy for MOs and PGs on Bond ● Transparent allocation of location of postings ● Facilitate recruitment of regular posts from outside the state by introducing ﬂexibility in selection process

Increase the attractiveness ● Increase salaries substantially in regular appointments, of the government sector including NPA. Restrict private practice by government for MOs doctors. ● Increase salaries for contractual positions in some rural districts by using the ﬂexibility allowed by NHM ● District level supplementation for remuneration

Improve supportive ● Facilitate enrolment of rural students services and other benefits to improve retention in ● Improve financial and non-financial incentives in less remote areas desirable locations. Provide free hostel accommodation, transport etc. ● Ensure career pathway, improved by serving in rural & remote areas:

1- Points in PG entrance for MOs serving in tribal areas 2- Sponsor MOs in rural, remote & tribal areas to attend special PG family medicine courses (post MBBS) 3- Time bound transfer option for doctors posted in tribal areas 4- Compulsory posting (around 20% part of career) in tribal areas for every regular MO/specialist 5- Making at least 3-year service in tribal areas compulsory for promotions

5 Is the production of nurses in Chhattisgarh suﬃcient to meet current demand and how can recruitment and deployment process be improved?

A paradox of sorts is occurring for Staff Nurses (SNs) in the State. There exists simultaneously a significant number of vacant positions around 1500 in DHS and 1500 in DME in the public sector and a large oversupply of qualified nursing graduates seeking such roles. Essentially the labour market for SNs is not clearing.

Wages are not too low to attract nurses. Regular public sector jobs are the most ﬁnancially attractive jobs for SNs. Particularly regular SNs who earn double the salary of contractual SNs. It appears that the recent increase in supply of nurses is putting downward pressure on salaries, especially in private sector, making public sector jobs even more attractive.

Reserved posts for scheduled tribes (ST) (in some districts as high at 50%) does not seem to be an obstacle. In many areas 50% of the newly registering nurses are ST.

Delays in recruitment drives need to be addressed. Approved Regular Staﬀ Nurses posts in Chhattisgarh 6000 4803 5000

4000 3275 3000

2000

1000

0 2016 2017 2018 Working Vacant

There are an increasing number of nursing graduates in the State driven by a boom in private nursing education. There are 84 GNM and 87 BSc nursing colleges. This mushrooming has created challenges in ensuring quality of education which need to be redressed.

According to estimates, the public sector currently absorbs 20% of the registered nurses in the State with another 20-30% being absorbed by the private sector. The majority of the remaining 50% of nurses are unemployed, with small portions having found work in other sectors, or having lost faith in the local labour market left the pool of job seekers or the State. Registered nurses 25,000-27,000

Private sector Public Sector Other Sector 6,000-9,000 6,000 ?

Out of Iabour Unemployed Migration market 7,000 ? ?

6 Recommendation Policy Options Develop a more eﬀective ● Developing fast track time-bound recruitment policies to ﬁll and transparent the vacancies (simplify procedures, reinforce admin recruitment process capacity, better coordination between MoH and Ministry of Finance, make the recruitment and deployment more transparent, etc.) ● Focus on DME which has very high regular Nurses vacancies ● Having a regular annual recruitment drive will allow a better match between the demand and the supply for the health workforce ● Pro-actively identify unemployed nurses and retrain/train them, including for the Health and Wellness Centres roll out ● Prioritize recruitment of nurses who have been trained through government sponsored schemes

Improve accreditation and ● Strengthening regulation to improve quality of education in quality control private nursing schools over quantity mechanisms for all educational institutions ● Decide seats in private sector based on market availability and demand for nurses ● Start nurse mentoring programmes

Reduce the salary gap ● Increase the salary of contractual nurses between contractual and regular nurses ● Give extra points for experience in contractual jobs when recruiting for regular posts ● Convert contractual nurses into regular cadre after a minimum length of service

Policy Recommendations for Assistant Medical Oﬃcer (AMO) Cadre

AMOs are the three-year diploma clinicians working mainly in rural PHCs. They have been the backbone of primary care provisioning in the state. There are around 1200 AMOs working. Although a successful innovation started by Chhattisgarh, the course was closed after producing around 1300 diploma graduates.

Recommendations Policy Options Reduce salary diﬀerence ● Introducing policy to facilitate transitioning from contractual between Contractual and to regular AMO Regular AMOs and create a career pathway for this ● Prioritising contractual AMOs for MLHP role in Health and cadre Wellness Centres ● Creating an attractive career pathway for this cadre

Improve capacity of AMOs ● Invest further in skills of AMOs ● The state can consider restarting the 3 Year Diploma/BSc Community Health course in order to meet the long term primary care provisioning needs of rural and remote areas

What are the key health workforce elements to consider for a successful rolling out of the Health and Wellness Centers in Chhattisgarh?

Health and Wellness Centers (HWCs) for Comprehensive Primary Health Care is a Flagship Programme. Korba district of Chhattisgarh was the pioneer in starting HWCs in 2015 and

7 reaching 70 centres in 2017. The national roll-out of HWCs was inaugurated by the Prime Minister in Bijapur, Chhattisgarh in 2018. Chhattisgarh has been innovative leader in HRH staﬃng for the rollout of HWCs.

AMOs as Mid-level health providers are an innovative HRH solution the state adopted to address the health workforce needs of HWCs, making it the ﬁrst state to introduce this model in the country. The state has also built a system to train enough MLHPs from BSc. Nurses. For the current six-month MLHP course the State has built a capacity to train more than 1000 MLHPs annually, mostly in District Hospitals designated as Programme Study Centres. There is a plan to add more study centers, especially Medical Colleges in order to improve quality. The current position is that the state has enough nurses and does not need to include other streams to get enough number of MLHPs.

Nevertheless, there are three key issues that will need to be addressed regarding the production of MLHPs in Chhattisgarh – 1. Regional Distribution; 2. Quality of Training; and 3. Clarity Regarding Roles and Responsibilities

Auxiliary Nurse Midwives (ANMs), male multipurpose workers and ASHAs constitute other elements of the envisioned Primary Health Care Team. Currently the majority of the subcentres do not have 2nd ANMs which is needed for successful rollout. There is, therefore, a need to recruit 3100 more ANMs and consider role division between the two ANMs. The modest amount team incentives in comparison to the performance-based incentives for MLHPs needs to also be addressed.

Policy recommendations for a successful rolling out of the Health and Wellness Centers in Chhattisgarh

Recommendations Policy Options Education and training ● Ensuring quality in training of MLHPs, their continuous skill building on the job and mentoring

Roles and responsibilities ● Clarifying role of HWCs, thereby MLHPs, in curative care - i.e. the approach should be “resolve more and refer some” and not mainly referral based ● Ensuring two ANMs per HWC, completing recruitments of sanctioned posts of 2nd ANMs ● Team-Building of HWC workforce ● Dovetailing of roles between AMOs and Nurse MLHPs ● Equitable incentives for ANMs and staﬀ other than MLHPs ● Redeﬁning the role of male MPWs, to align with the required functions in HWCs

Lessons learned and building on successes in Chhattisgarh ● Enough production of HRH in state esp. nurses to ﬁll vacancies

● Increase in production of doctors

● Recruitments have improved to some extent in last 4-5 years

● Collaborations for training of HRH with Teaching Institutions like AIIMS, NIMHANS etc.

● Short Courses to enable task shifting/multi-skilling e.g. 3-month course on Pediatric skills for MOs in collaboration with AIIMS

8 ● Many Studies of HRH issues in Chhattisgarh, capacity to undertake required analysis. A shared understanding of HRH issues and solutions in diﬀerent sections of health department.

Moving forward Chhattisgarh successfully increased and strengthened its health workforce over the last decades and has been a pioneer in innovating human resources for heath cadres at the primary care level. As such the health and wellness centers have been kickstarted in the state though the use of Assistant Medical Oﬃcers.

However, challenges remain notably in terms of filling the pervasive vacancies that hinder access to publicly funded health care. Strengthening the production of doctors and ensuring sufficient faculty capacity is going to be a priority in the state. Yet, for some cadres such as nurses, there is already sufficient production to fill the currently vacant posts. Therefore, swift policy response is possible. Nevertheless, to balance out the geographical distribution of health workers across the state explicit and proactive policy action will need to be adopted.

The HLMA policy recommendations complement and strengthen some of the recent initiatives and policies adopted in Chhattisgarh. As such it is an opportune time to develop a new health workforce strategy. This will be a key element to ensure the successful implementation of the HLMA policy recommendations and develop a future health workforce ﬁt for delivering the UHC that the citizens of Chhattisgarh deserve.