Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-025979 on 27 May 2019. Downloaded from Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data Anup Karan,1 Himanshu Negandhi,2 Rajesh Nair,3 Anjali Sharma,4 Ritika Tiwari,4 Sanjay Zodpey3 To cite: Karan A, Negandhi H, ABSTRACT Strengths and limitations of this study Nair R, et al. Size, composition Objectives We provide new estimates on size, and distribution of human composition and distribution of human resource for health resource for health in ► Size and composition, density, and distribution in India and compare with the health workers population India: new estimates using across states, rural–urban and public–private sec- National Sample Survey and ratio as recommended by the WHO. We also estimate size tors of human resource for health in India have been Registry data. BMJ Open of non-health workers engaged in health sector and the estimated as of January 2016. 2019;9:e025979. doi:10.1136/ size of technically qualified health professionals who are ► The study for the first time estimates non-health bmjopen-2018-025979 not a part of the health workforce. workers engaged in the health sector and technical- ► Prepublication history and Design Nationally representative cross-section household ly qualified health professionals who are not part of additional material for this survey and review of published documents by the Central the current workforce. paper are available online. To Bureau of Health Intelligence. ► The registry data of the health professionals in India view these files, please visit Setting National. are inadequately updated, and the National Sample the journal online (http:// dx. doi. Participants Head of household/key informant in a Survey data provide information on a self-reported org/ 10. 1136/ bmjopen- 2018- sample of 101 724 households. basis. 025979). Interventions Not applicable. ► There could be an overlap in the definition and Received 14 August 2018 Primary and secondary outcome measures The reporting of nurses and midwives in the National Revised 8 December 2018 primary outcome was the number and density of health Sample Survey data. Accepted 30 January 2019 workers,and the secondary outcome was the percentage http://bmjopen.bmj.com/ of health workers who are technically qualified and the percentage of individuals technically qualified and not in INTRODUCTIOn workforce. The size and composition of human resource Results The total size of health workforce estimated from the National Sample Survey (NSS) data is for health (HRH) in India have significantly © Author(s) (or their 3.8 million as of January 2016, which is about changed during the last decade. Most existing employer(s)) 2019. Re-use literature on HRH in India reports that the permitted under CC BY-NC. No 1.2 million less than the total number of health country is well short of the WHO’s recom- on September 26, 2021 by guest. Protected copyright. commercial re-use. See rights professionals registered with different councils and and permissions. Published by associations. The density of doctors and nurses and mendation of the minimum threshold of 22.8 BMJ. midwives per 10 000 population is 20.6 according to skilled health professionals per 10 000 popu- 1–5 1Indian Institute of Public Health, the NSS and 26.7 based on the registry data. Health lation. Recently, WHO, drawing evidence Delhi, Public Health Foundation workforce density in rural India and states in eastern from the Organisation for Economic Co-oper- of India, Gurugram, Haryana, India is lower than the WHO minimum threshold of ation and Development countries, revised the India 2 22.8 per 10 000 population. More than 80% of doctors minimum need as 44.5 health professionals Indian Institute of Public Health, 6 Delhi, Public Health Foundation and 70% of nurses and midwives are employed in the per 10 000 population. The Global Health of India, Gurugram, Haryana, private sector. Approximately 25% of the currently Workforce Alliance and WHO categorised India working health professionals do not have the required India among the 57 most severe crisis-facing 3 Indian Institute of Public Health, qualifications as laid down by professional councils, countries in terms of availability of HRH.7 8 Delhi, Public Health Foundation while 20% of adequately qualified doctors are not in The recent health sector reforms in of India, Gurugram, Haryana, the current workforce. India India, particularly since the launch of the Conclusions Distribution and qualification of health 4Academics, Public Health National Rural Health Mission, have empha- Foundation of India, Gurugram, professionals are serious problems in India when sised on strengthening HRH in the public compared with the overall size of the health workers. Haryana, India sector system.9 For instance, the central Policy should focus on enhancing the quality of health and many state governments took proactive Correspondence to workers and mainstreaming professionally qualified steps towards rural posting for public sector Dr Anup Karan; persons into the health workforce. anup. karan@ iiphd. org doctors. Several states contracted private Karan A, et al. BMJ Open 2019;9:e025979. doi:10.1136/bmjopen-2018-025979 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-025979 on 27 May 2019. Downloaded from sector practitioners and non-governmental organisations All these estimates are far lower than the minimum (NGOs) to bridge the manpower gaps at primary health thresholds of 22.8 health workers per 10 000 population centre levels in rural and suburban areas.9 On the supply and 10 doctors per 10 000 population. These studies side, the last one decade and a half witnessed a rise in the also provided estimates of other health workers such as medical colleges, nursing institutions and other technical nurses and midwives, AYUSH doctors, and pharmacists. education institutions in medical and paramedical disci- Other studies have highlighted a lop-sided distribution plines.10 11 of HRH across Indian states with comparatively poorer Healthcare services in India are offered by a varied states of the north and east, which have low density of range of professionals trained in different specialties of health workers compared with Delhi and South Indian medicine and healthcare. The entire health workforce states.3 5 Anand and Bärnighausen1 in an India–China includes many informal medical practitioners, such as comparative study estimated 1.9 million health workers registered medical practitioners (RMPs) (including tradi- on the basis of the Census 2001 data. The density of tional birth attendants, faith healers, snakebite curers, doctors and nurses taken together reported in the study is bonesetters and so on) with or without any formal educa- 13.6 per 10 000 population,2 which is far lower compared tion or skills training. RMPs are often the first point of with the estimates in other studies.3 5 In a recent study, contact for treatment for a large proportion of popula- using the NSSO 2011–2012 data, Rao et al16 estimated tion living in rural and remote areas. that there were 2.5 million health workers (density of 20.9 Among the formal healthcare providers, allopathic workers) in India. The study also reported that more than doctors, which include physicians, surgeons, specialists half of the total number of health workers are unqual- and medical graduates with a bachelor’s or postgrad- ified, and adjusting for the right qualifications leaves uate specialist diploma or degree, are registered with India with a density of 9.1 workers per 10 000 population. the Medical Council of India (MCI), and dentists hold a Hazarika,14 however, on the basis of government records similar degree and are registered with the Dental Council reported higher number of doctors (0.76 million) and (DC) of India. AYUSH doctors (an indigenous Indian nurses (1.6 million) for the years 2010 and 2011, respec- system of medicine comprising Ayurvedic, Yoga, Unani, tively. A report by Klynveld Peat Marwick Goerdeler and Siddha and Homeopathy) are bachelor’s or postgraduate the Federation of Indian Chambers of Commerce and degree holders in AYUSH. Their registering institution Industry, using data from the Central Bureau of Health is the Central Council of Indian Medicine or the Central Intelligence, estimated the total size of health workers in Council of Homoeopathy, and they are authorised to India as 4.7 million in year 2015, consisting of 0.9 million dispense medicines and conduct surgery using their doctors, 0.69 million AYUSH doctors and 1.6 million respective fields of specialisation. AYUSH doctors are registered nurses.16 an integral part of HRH in India as their professions are Earlier studies using prereforms period data do not http://bmjopen.bmj.com/ recognised by a Parliament Act.3–5 capture recent changes in the HRH situation. Moreover, Another group of health workforce includes subordi- only a couple of studies provide data on the situation of nate staff which includes, nurses, auxiliary nurses and HRH gaps at the state level and rural–urban disaggre- midwives (ANMs), physiotherapists, and diagnostic and gation. The existing literature does not provide insights other technicians. Nurses have a diploma in general into the size of allied health professionals and support nursing and midwifery or a bachelor’s degree or a post- staff. Our paper aims to fill these gaps in the literature by graduate degree registered with the Indian Nursing providing the latest estimates of HRH as of January 2016 Council (INC). ANMs, who mainly work as subordinates at all-India and state levels and its rural–urban disaggrega- on September 26, 2021 by guest. Protected copyright. to the main nurse, have a diploma in auxiliary nurse tion. In addition, for the first time we report estimates of midwifery.