Achieving universal health coverage and sustainable development goals by 2030: investment estimates to increase production of health professionals in India.

BACKGROUND: COVID-19 has reinforced the importance of having a sufficient, well-distributed and competent health workforce. In addition to improving health outcomes, increased investment in health has the potential to generate employment, increase labour productivity and foster economic growth. We estimate the required investment for increasing the production of the health workforce in India for achieving the UHC/SDGs. METHODS: We used data from National Health Workforce Account 2018, Periodic Labour Force Survey 2018-19, population projection of Census of India, and government documents and reports. We distinguish between total stock of health professionals and active health workforce. We estimated current shortages in the health workforce using WHO and ILO recommended health worker:population ratio thresholds and extrapolated the supply of health workforce till 2030, using a range of scenarios of production of doctors and nurses/midwives. Using unit costs of opening a new medical college/nursing institute, we estimated the required levels of investment to bridge the potential gap in the health workforce. RESULTS: To meet the threshold of 34.5 skilled health workers per 10 000 population, there will be a shortfall of 0.16 million doctors and 0.65 million nurses/midwives in the total stock and 0.57 million doctors and 1.98 million nurses/midwives in active health workforce by the year 2030. The shortages are higher when compared with a higher threshold of 44.5 health workers per 10 000 population. The estimated investment for the required increase in the production of health workforce ranges from INR 523 billion to 2 580 billion for doctors and INR 1 096 billion for nurses/midwives. Such investment during 2021-2025 has the potential of an additional employment generation within the health sector to the tune of 5.4 million and to contribute to national income to the extent of INR 3 429 billion annually. CONCLUSION: India needs to significantly increase the production of doctors and nurses/midwives through investing in opening up new medical colleges. Nursing sector should be prioritized to encourage talents to join nursing profession and provide quality education. India needs to set up a benchmark for skill-mix ratio and provide attractive employment opportunities in the health sector to increase the demand and absorb the new graduates.

Size, composition and distribution of health workforce in India: why, and where to invest?

BACKGROUND: Investment in human resources for health not only strengthens the health system, but also generates employment and contributes to economic growth. India can gain from enhanced investment in health workforce in multiple ways. This study in addition to presenting updated estimates on size and composition of health workforce, identifies areas of investment in health workforce in India. METHODS: We analyzed two sources of data: (i) National Health Workforce Account (NHWA) 2018 and (ii) Periodic Labour Force Survey 2017-2018 of the National Sample Survey Office (NSSO). Using the two sources, we collated comparable estimates of different categories of health workers in India, density of health workforce and skill-mix at the all India and state levels. RESULTS: The study estimated (from NHWA 2018) a total stock of 5.76 million health workers which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacist (1.20 million), dentists (0.27 million), and traditional medical practitioner (AYUSH 0.79 million). However, the active health workforce size estimated (NSSO 2017-2018) is much lower (3.12 million) with allopathic doctors and nurses/midwives estimated as 0.80 million and 1.40 million, respectively. Stock density of doctor and nurses/midwives are 8.8 and 17.7, respectively, per 10,000 persons as per NHWA. However, active health workers' density (estimated from NSSO) of doctor and nurses/midwives are estimated to be 6.1 and 10.6, respectively. The numbers further drop to 5.0 and 6.0, respectively, after accounting for the adequate qualifications. All these estimates are well below the WHO threshold of 44.5 doctor, nurses and midwives per 10,000 population. The results reflected highly skewed distribution of health workforce across states, rural-urban and public-private sectors. A substantial proportion of active health worker were found not adequately qualified on the one hand and on the other more than 20% of qualified health professionals are not active in labor markets. CONCLUSION: India needs to invest in HRH for increasing the number of active health workers and also improve the skill-mix which requires investment in professional colleges and technical education. India also needs encouraging qualified health professionals to join the labor markets and additional trainings and skill building for already working but inadequately qualified health workers.

Assessment of health professional education across five Asian countries-a protocol.

BACKGROUND: There is an increasing consensus globally that the education of health professionals is failing to keep pace with scientific, social, and economic changes transforming the healthcare environment. This catalyzed a movement in reforming education of health professionals across Bangladesh, China, India, Thailand, and Vietnam who jointly volunteered to implement and conduct cooperative, comparative, and suitable health professional education assessments with respect to the nation's socio-economic and cultural status, as well as domestic health service system. METHODS: The 5C network undertook a multi-country health professional educational study to provide its countries with evidence for HRH policymaking. Its scope was limited to the assessment of medical, nursing, and public health education at three levels within each country: national, institutional, and graduate level (including about to graduate students and alumni). RESULTS: This paper describes the general issues related to health professional education and the protocols used in a five-country assessment of medical, nursing, and public health education. A common protocol for the situation analysis survey was developed that included tools to undertake a national and institutional assessment, and graduate surveys among about-to-graduate and graduates for medical, nursing, and public health professions. Data collection was conducted through a mixture of literature reviews and qualitative research. CONCLUSIONS: The national assessment would serve as a resource for countries to plan HRH-related future actions.

Enhancing public health practice through a capacity-building educational programme: an evaluation.

BACKGROUND: The Post-Graduate Diploma in Public Health Management, launched by the Govt. of India under the aegis of the National Rural Health Mission in 2008, aims to enhance the managerial capabilities of public health professionals to improve the public health system. The Govt. of India invested enormous resources into this programme and requested an evaluation to understand the current processes, assess the graduates' work performance and identify areas for improvement. METHODS: Quantitative telephone surveys as well as qualitative in-depth interviews were used. Graduates from the first three batches, their supervisors, peers and subordinates and faculty members were interviewed. Quantitative data were analysed using proportions, means and interpretative descriptions. Qualitative analyses involved transcription, translation, sorting, coding and filing into domains. RESULTS: Of the 363 graduates whose contact details were available, 138 could not be contacted. Two hundred twenty-three (223) graduates (61.43% of eligible participants) were interviewed by telephone; 52 in-depth interviews were conducted. Of the graduates who joined, 63.8% graduates were motivated to join the programme for career advancement and gaining public health knowledge. The content was theoretically good, informative and well-designed. Graduates expressed need for more practical and group work. After graduating, they reported being equipped with some new skills to implement programmes effectively. They reported that attitudes and healthcare delivery practices had improved; they had better self-esteem, increased confidence, better communication skills and implementation capacity. While they were able to apply some skills, they encountered some barriers, such as governance, placements, lack of support from the system and community, inadequate implementation authority and lack of planning by the state government. Incentives (both monetary and non-monetary) played a major role in motivating them to deliver public health services. They suggested that states should nominate candidates expected to make a significant contribution to the health system, recognition from a relevant authoritative national body and need for a placement cell, especially for the self-sponsored candidates. CONCLUSIONS: A continuous mechanism for interaction and dialogue with the graduates during and after completion of the programme should be designed. This evaluation helped by providing inputs for refining the programme.

Forecasting the future need and gaps in requirements for public health professionals in India up to 2026.

Current ambitious reforms in India mean that public health professionals (PHPs) will become an increasingly vital component of the health workforce. Despite a rapid growth in schools of public health in India, uptake of places by students without a medical background is low. This paper reports the results of an exercise to estimate the baseline supply of, and need for, PHPs in India in 2017 and to forecast possible supply-need scenarios up to 2026. Supply was estimated using the stock and flow approach and the service-target approach was used to estimate need. The additional need resulting from development of a new public health cadre, as stated in the National Health Policy 2017, was also included. Supply-need gaps were forecast according to three scenarios, which varied according to the future intensity of policy intervention to increase occupancy of training places for PHPs from a non-medical background: "best guess" (no intervention), "optimistic" (feasible intervention), and "aspirational" (significant intervention) scenarios. In the best guess scenario in 2017, i.e. with a low non-medical place occupancy of 60%, there is a supply-need gap of around 28 000 PHPs. In the absence of any intervention to increase place occupancy, this shortfall is forecast to increase to 45 000 PHPs by the year 2026. By contrast, in the aspirational scenario, i.e. with a high place occupancy of 75% for non-medical places, the baseline gap for 2017 of almost 26 000 PHPs reduces by 2026 to around 21 000 PHPs. By 2026, most new PHPs will be produced by public health training programmes offered by institutions other than medical colleges. Without significant interventions, India is likely to have a significant shortfall in PHPs in 2026. Policy-makers will have to carefully examine issues surrounding the current low uptake of non-medical public health seats and review the current framework regulating training of PHPs, in order to respond adequately to future requirements.

Online resources for occupational health physicians.

Periodic retraining ensures that experts are updated in the advances in the science and methods of their profession. Such periodic retraining is sparsely accessible to Indian occupational health physicians and researchers. However, there is significant material that is available online in occupational health and related fields. This information is open-source and is freely available. It does not require any special subscription on the client's part. This information can supplement the efforts of motivated occupational health practitioners in India.