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.

Strengthening institutions for public health education: results of an SWOT analysis from India to inform global best practices.

BACKGROUND: Developing public health educational programs that provide workers prepared to adequately respond to health system challenges is an historical dilemma. In India, the focus on public health education has been mounting in recent years. The COVID-19 pandemic is a harbinger of the increasing complexities surrounding public health challenges and the overdue need to progress public health education around the world. This paper aims to explore strengths and challenges of public health educational institutions in India, and elucidate unique opportunities to emerge as a global leader in reform. METHODS: To capture the landscape of public health training in India, we initiated a web-based desk review of available offerings and categorized by key descriptors and program qualities. We then undertook a series of in-depth interviews with representatives from a purposively sample of institutions and performed a qualitative SWOT analysis. RESULTS: We found that public health education exists in many formats in India. Although Master of Public Health (MPH) and similar programs are still the most common type of public health training outside of community medicine programs, other postgraduate pathways exist including diplomas, PhDs, certificates and executive trainings. The strengths of public health education institutions include research capacities, financial accessibility, and innovation, yet there is a need to improve collaborations and harmonize training with well-defined career pathways. Growing attention to the sector, improved technologies and community engagement all hold exciting potential for public health education, while externally held misconceptions can threaten institutional efficacy and potential. CONCLUSIONS: The timely need for and attention to public health education in India present a critical juncture for meaningful reform. India may also be well-situated to contextualize and scale the types of trainings needed to address complex challenges and serve as a model for other countries and the world.

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.

A study of organizational versus individual needs related to recruitment, deployment and promotion of doctors working in the government health system in Odisha state, India.

BACKGROUND: An effective health workforce is essential for achieving health-related new Sustainable Development Goals. Odisha, one of the states in India with low health indicators, faces challenges in recruiting and retaining health staff in the public sector, especially doctors. Recruitment, deployment and career progression play an important role in attracting and retaining doctors. We examined the policies on recruitment, deployment and promotion for doctors in the state and how these policies were perceived to be implemented. METHODS: We undertook document review and four key informant interviews with senior state-level officials to delineate the policies for recruitment, deployment and promotion. We conducted 90 in-depth interviews, 86 with doctors from six districts and four at the state level to explore the perceptions of doctors about these policies. RESULTS: Despite the efforts by the Government of Odisha through regular recruitments, a quarter of the posts of doctors was vacant across all institutional levels in the state. The majority of doctors interviewed were unaware of existing government rules for placement, transfer and promotion. In addition, there were no explicit rules followed in placement and transfer. More than half (57%) of the doctors interviewed from well-accessible areas had never worked in the identified hard-to-reach areas in spite of having regulatory and incentive mechanisms. The average length of service before the first promotion was 26 (±3.5) years. The doctors expressed satisfaction with the recruitment process. They stated concerns over delayed first promotion, non-transparent deployment policies and ineffective incentive system. Almost all doctors suggested having time-bound and transparent policies. CONCLUSIONS: Adequate and appropriate deployment of doctors is a challenge for the government as it has to align the individual aspirations of employees with organizational needs. Explicit rules for human resource management coupled with transparency in implementation can improve governance and build trust among doctors which would encourage them to work in the public sector.

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.

Community health workers for universal health-care coverage: from fragmentation to synergy.

To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs' contribution. The current drive towards universal health coverage (UHC) presents an opportunity to enhance people's access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs' skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress.

Pour parvenir à une couverture sanitaire universelle, les systèmes de santé devront étendre leur portée à toutes les communautés, y compris celles qui sont les plus pauvres et les plus difficiles d'accès. Depuis la Déclaration de Alma-Ata, le soutien inégal des agents sanitaires des collectivités et l'échec de leur intégration dans les systèmes de santé ont empêché la pleine réalisation de leur contribution potentielle dans le contexte des soins de santé primaires. Le développement et le maintien des programmes des agents sanitaires des collectivités se heurtent à une multitude de défis à relever: mauvaise planification; multitude d'acteurs concurrents avec peu de coordination; formation fragmentée et spécifique aux maladies; gestion et financement à l'initiative des donateurs; lien ténu avec le système de santé; coordination, supervision et soutien de mauvaise qualité, et sous-reconnaissance de la contribution des agents sanitaires des collectivités.La campagne actuelle vers une couverture sanitaire universelle offre une opportunité d'améliorer l'accès des personnes à des services de santé, ainsi que leur confiance, demande et utilisation de tels services par le biais des agents sanitaires des collectivités. Pour que leur potentiel puisse être pleinement réalisé, les agents sanitaires des collectivités devront toutefois être mieux intégrés dans les systèmes nationaux de soins de santé en termes d'embauche, de supervision, de soutien et d'évolution de carrière. Les partenaires au niveau du monde, du pays et du district devront harmoniser et synchroniser leurs engagements dans le soutien aux agents sanitaires des collectivités tout en maintenant suffisamment de flexibilité pour permettre aux programmes d'innover et de répondre aux besoins locaux. Un leadership fort du secteur public sera nécessaire pour faciliter l'alignement avec les cadres politiques nationaux et la coordination dirigée par le pays et pour réaliser des synergies et des responsabilités, la couverture universelle et la durabilité. En avançant vers la couverture sanitaire universelle, il y a beaucoup à gagner en investissant dans l'acquisition de compétences des agents sanitaires des collectivités et en les soutenant en tant que membres à part entière des équipes de santé. Les investissements autonomes au bénéfice des agents sanitaires des collectivités ne sont pas des raccourcis vers le progrès.

A fin de lograr la cobertura universal de la salud, los sistemas sanitarios deben llegar a todas las comunidades, incluidas las más pobres y de difícil acceso. Desde la conferencia de Alma-Ata, el apoyo inconstante de los trabajadores comunitarios de salud (TCS) y la falta de integración de estos en el sistema sanitario han impedido la plena realización de su contribución potencial en el contexto de la atención primaria de la salud. La ampliación y el mantenimiento de los programas de trabajadores comunitarios de salud suponen muchos desafíos: la mala planificación, los agentes múltiples que compiten con insuficiente coordinación, la fragmentación en los programas de capacitación orientados a combatir enfermedades específicas, la gestión y la financiación impulsadas por los donantes, la escasa unión con el sistema sanitario, la falta de coordinación, supervisión y apoyo, y la infravaloración de la contribución de los trabajadores comunitarios de la salud.El avance actual hacia la cobertura universal de la salud (CUS) ofrece una oportunidad para mejorar el acceso de la población a los servicios de salud, así como para aumentar la confianza, la demanda y el uso de dichos servicios a través de los trabajadores comunitarios de salud. Sin embargo, es necesario integrar mejor a los trabajadores comunitarios de salud, en términos de empleo, supervisión, apoyo y desarrollo profesional, en los sistemas nacionales sanitarios para aprovechar plenamente su potencial. Los socios a nivel mundial, nacional y local deben armonizar y sincronizar su compromiso a favor de los trabajadores comunitarios de salud, manteniendo la flexibilidad suficiente para que los programas tengan capacidad de innovación y respuesta frente a las necesidades locales. Se requiere un fuerte liderazgo por parte del sector público para facilitar la alineación con los marcos de las políticas nacionales y la coordinación dirigida por el país, y para lograr sinergias y la rendición de cuentas, la cobertura universal y la sostenibilidad. En la consecución de la cobertura universal de la salud, pueden obtenerse grandes beneficios si se invierte en el desarrollo de competencias de los trabajadores comunitarios de salud, y se les apoya como miembros valiosos del equipo sanitario. Por el contrario, las inversiones aisladas en trabajadores comunitarios de salud no son atajos hacia el progreso.

Need and supply gap in occupational health manpower in India.

Industrial growth in India has resulted in increased employment opportunities, thereby inflating the size of the workforce engaged in both organized and unorganized sectors. This workforce is exposed to various occupational factors at workplace and hence is susceptible to occupational diseases, which requires trained occupational health manpower. The present study is undertaken to estimate the need and supply gap of occupational health manpower, based on present regulations. The total workforce in the organized sector in India is 26.92 million. There are 254,951 working registered industrial factories in India, with about 11.16 million workers. These factories have employed 6953 factory medical officers (FMOs) and 2308 safety officers (SOs). Hence, for 26.92 million of total workforce engaged in organized sector, we would require a total of 16,728 FMOs and 5619 SOs, thereby estimating the deficit of 58% for FMOs and 59% for SOs based on current ratio of employment.

Perceived Gaps in Academic Training and Expectations From Refresher Training in Primary Care Nurses at an Urban Metropolis in Northern India: A Qualitative Study.

Background Nursing professionals, comprising the largest workforce engaged in the primary healthcare system, play a pivotal role in addressing population health needs. However, gaps in the training of nurses and midwives in lower-middle-income countries may undermine their performance and necessary skill development for fulfilling key population health needs. Substantial challenges exist in improving the regular curricular and refresher training of diplomate nurses and midwives working in primary care facilities and supporting both clinical care and health promotion functions. The study objective was to conduct a gap analysis in the present nursing curriculum and training profile of general duty midwives working in urban primary health facilities and understand their expectations and preferences from the planned refresher training course.  Methods We conducted a qualitative explorative study among General Nursing midwives (GNMs) working in urban primary health facilities in the Gurugram district of Haryana, India to conduct a gap analysis in their present curriculum and training preferences.  Results A total of 17 nurses with a mean (SD) age of 33.52 (4.75) years and an average nursing work experience of 5.35 (0.56) years were interviewed in-depth. Lack of practical applicability, complex study material, inexperienced tutors, and weak English language comprehension were key barriers in the existing nursing curriculum. The nurses expressed willingness to participate in refresher training with varied expectations, although there existed a distinct preference for short, flexible, and blended online-offline modes of training.  Conclusions Strengthening GNM nursing education should be prioritized in Indian health settings with the focus on improving student comprehension through vernacular instruction when feasible, and capacity building of tutors, with avenues for continued training and education. There is also a need for strengthening the curriculum related to key emergent public health challenges related to non-communicable diseases and mental health, as also skills for client and patient counseling and communication.

COVID-19 vaccine acceptance among healthcare workers in India: Results from a cross-sectional survey.

Remarkable scientific progress has enabled expeditious development of effective vaccines against COVID-19. While healthcare workers (HCWs) have been at the frontline of the pandemic response, vaccine acceptance amongst them needs further study. We conducted a web-based survey to assess vaccine acceptance among HCWs in India between January and February 2021, shortly after the launch of India's vaccination campaign. Descriptive statistics were used to examine respondent demographics and Likert scale responses. Binomial logistic regression analyses were used to identify factors associated with vaccine acceptance. The survey yielded 624 respondents from 25 states and five union territories in India; 53.5% were male, and median age was 37 years (IQR 32-46). Amongst all respondents, 84.1% (525/624) supported COVID-19 vaccines, and 63.2% (141/223) of those unvaccinated at the time of survey administration were willing to accept a vaccine. Trust in government sources, healthcare providers or scientific journal articles for COVID-19 related information was reported by 66.8%, while confidence in social media for this information was reported by only 4.5%. Amongst those who had not yet received a COVID-19 vaccine, factors independently associated with vaccine acceptance included age (aOR 3.50 [95% CI, 1.04-11.76] for those above 45 years compared to younger HCWs aged 18-29 years), belief in vaccine effectiveness and safety (aOR 3.78 [95% CI 1.15-12.38]), and provision of free/no-cost vaccine (aOR 2.63 [95% CI, 1.06-6.50]). Most respondents (80%) were confident about their hospital being equipped to efficiently rollout COVID-19 vaccines to the general population. While overall attitudes towards COVID-19 vaccination were positive among HCWs in India, acceptance was lower among healthier and younger HCWs. Data availability on vaccine safety and effectiveness, and cost considerations were important for acceptance. Targeted interventions are needed to improve vaccine acceptance amongst HCWs, since they are critical in promoting vaccine acceptance amongst the general population.

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.