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Health Workforce in India: Assessment of Availability, Production and Distribution Original Research Access this article online Website: www.searo.who.int/publications/ journals/seajph DOI: 10.4103/2224-3151.122944 Quick Response Code: Health workforce in India: assessment of availability, production and distribution Indrajit Hazarika ABSTRACT Australian Health Workforce Institute, University of Melbourne, Melbourne, Australia, Public Health Background: India faces an acute shortage of health personnel. Together with Foundation of India, Vasant Kunj inequalities in distribution of health workers, this shortfall impedes progress towards Institutional Area, New Delhi, India achievement of the Millennium Development Goals. The aim of this study was to Address for correspondence: assess health‑workforce distribution, identify inequalities in health‑worker provision Dr Indrajit Hazarika, Australian Health and estimate the impact of this maldistribution on key health outcomes in India. Workforce Institute, University of Melbourne, Level 3, 766 Elizabeth Materials and Methods: Health‑workforce availability and production were Street, Parville, Victoria 3010, Australia. assessed by use of year‑end data for 2009 obtained from the Indian Ministry of E‑mail: [email protected] Statistics and Programme Implementation. Inequalities in the distribution of doctors, dentists, nurses and midwives were estimated by use of the Gini coefficient and the relation between health‑worker density and selected health outcomes was assessed by linear regression. Results: Inequalities in the availability of health workers exist in India. Certain states are experiencing an acute shortage of health personnel. Inequalities in the distribution of health workers are highest for doctors and dentists and have a significant effect on health outcomes. Conclusion: Although the production of health workers has expanded greatly in recent years, the problems of imbalances in their distribution persist. As India seeks to achieve universal health coverage by 2020, the realization of this goal remains challenged by the current lack of availability and inequitable distribution of appropriately trained, motivated and supported health workers. Key words: Availability, distribution, health workers, inequalities, production INTRODUCTION development.[4] There have been efforts to expand the health workforce to meet demand. However, these In low-income countries, despite the availability of effective efforts have been hampered by increases in factors such interventions for many priority health problems and as population size, purchasing power for health services enhanced developmental assistance, progress towards within communities, life expectancy and the prevalence of the health Millennium Development Goals is impeded noncommunicable diseases and other chronic conditions.[5] by the shortage of trained, motivated and supported health workers.[1,2] Health workers play a central role in India is a conglomeration of states with diverse levels of ensuring the appropriate management of all aspects of the socioeconomic status, governance, health systems and health system: From logistics and facility management to health situations. As elsewhere, India has shortages and finances and health-care interventions.[3] Furthermore, maldistribution within its health workforce that have because a society’s health and its development are strongly contributed to inequities in health outcomes. India’s health linked, health workers have an indirect but crucial role workforce is a combination of both registered, formal in the achievement of sustainable human and economic health-care providers and informal medical practitioners, 106 WHO South-East Asia Journal of Public Health 2013 | April–June | 2(2) Hazarika: Health workforce in India the latter being the first point of contact for a large of vacant health-worker posts.[12] This latter analysis was proportion of the population.[6] limited to the public sector, since data on private-sector employment were not available. The country is unique because an expanding private for-profit sector is juxtaposed against a vast network of For state-wise analysis, population projections published public sector health facilities, which compete for a common by the Registrar General of India[13] were adjusted for pool of health human resources. Moreover, despite an differences in the projected and estimated populations increasing shortage of local health professionals, India from the 2011 census.[14] Densities of health workers has emerged as the most important source country in the were calculated from the workforce data described above global health-workforce market. According to the 2006 and census data on populations. National time trends for World Health Report, India had 0.60 doctors, 0.80 nurses, health-worker densities were calculated for 2000–2009. 0.47 midwives, 0.06 dentists and 0.56 pharmacists, Where subnational data were available, Lorenz curves respectively, per 1000 population. In absolute terms, and Gini indices were calculated to assess geographical reversal of the country’s shortfall in health workers was inequalities in doctor, dentist and nurse/midwife densities. estimated to require an investment of almost US$ 2 billion The Gini coefficient and Lorenz curve are measures of per year by 2015.[7] inequality and have been used in previous studies of health workforce inequality.[15,16] This inequality analysis was In addition to the known shortage of health workers, there based on the density at the first administrative division is a common perception that large in-country inequalities below national level, which is equivalent to the state exist in their distribution. To date, the evidence to support level in India. this proposition has been limited, owing to a lack of reliable disaggregated data at the country level. This Spearmans’s rank correlation coefficient was calculated study therefore used the most up-to-date data available to assess the relation between health-worker density and to assess the production, employment and distributional gross domestic product (GDP) at the state level. GDP patterns of health workers in India. Inequalities in data were derived from Reserve Bank of India Handbook health-worker distribution at the state level and the of Statistics on Indian Economy.[17] The relation between impact of this maldistribution on key health outcomes health-worker density and selected health outcomes was were also assessed. assessed by linear regression of data on infant mortality, maternal mortality, mortality in children younger than 5 years and measles immunization coverage from the Data AND METHODS 2010 Government of India Annual Report to the People on Health[18] against the density of health professionals. No ethics committee approval was required for this All variables were transformed into natural logarithms. research Data analyses were done with STATA version 10.0. Although WHO defines health workers[7] as “all people engaged in actions whose primary intent is to enhance health”, the term “health worker” in this study was RESULTS restricted to three categories: Doctors, dentists and nurses/midwives. Year-end data for 2009 on these health Health‑worker availability workers at the state level were obtained from the Indian Table 1 shows the absolute numbers and category-wise Ministry of Statistics and Programme Implementation’s density (per 1000 population) of doctors, dentists and 2011 Report on Health and Family Welfare.[8] In this nurses including midwives at the national and state levels. report, estimates on health-worker stock were derived In 2009, India had 761 806 doctors, 104 603 dentists and from three databases: (i) allopathic medical practitioners 1 650 180 nurses and midwives. At the national level, the registered with state medical councils; (ii) dental surgeons aggregate density of doctors, nurses and midwives was registered with the central/state dental councils; and (iii) 2.08 per 1000 population, which was lower than WHO’s information on registered nurses and midwives available to critical shortage threshold of 2.28.[7] There were gross the Indian Nursing Council and Central Bureau of Health inequalities in the availability of these health workers at Information, Directorate General of Health Services, the subnational level. For example, states such as Bihar, Government of India. In addition, national and state data Uttar Pradesh, Uttarakhand, Jharkhand and Chhattisgarh on the number of educational institutions in medicine, had especially severe shortages of health workers [less dentistry and nursing/midwifery, as well as the number than 1 per 1000 population; Table 1]. of admitted students, were extracted from the Medical Council of India (MCI), Dental Council of India (DCI) The 1993 World Development Report[19] recommended and Indian Nursing Council (INC) databases.[9 -11] Ministry that the ratio of nurses to doctors should exceed 2:1 of Health and Family Welfare documents were used to as a minimum, with 4:1 or higher considered best for assess the employment of health personnel and number cost-effective quality care. In 2009 the ratio of nurses WHO South-East Asia Journal of Public Health 2013 | April–June | 2(2) 107 Hazarika: Health workforce in India Table 1: State‑wise availability of doctors, dentists, nurses and midwives – 2009 States Population Health‑worker numbersa Health‑worker density per 1000 population Ratio of nurses a (million) Doctors Dentists GNMs ANMs Doctors Dentists Nurses and Combinede and midwives midwives per doctor Andhra Pradesh 83.11 62 349 6510 136
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