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.

Attributes of Standard Treatment Guidelines in Clinical Settings and Public Health Facilities in India.

Background: Standard Treatment Guidelines (STGs) are time-tested tool to improve healthcare quality and patient safety. This study was done to review the available guidelines and assess their essential attributes using AGREE reporting checklist 2016. Methods: Publications from PubMed, World Health Organization, Global Health Regional Libraries, Index Medicus, Google, Google Scholar, and insurers, state/central government portals were searched. Results: In total, 241 STGs met the inclusion criteria. A range of developers with a varying focus and priorities developed these guidelines (government mostly under national programs 134 (56%); professional associations 67 (28%), academic/research institutions 36 (15%); international agencies 4 [2%]). The government-led guidelines focused on program operations (mainly infections, maternal, and childcare), whereas insurers focused on surgical procedures for protection against fraudulent intentions for claims. The available STGs varied largely in terms of development process rigor, end-user involvement, updation, applicability, etc.; 12% guidelines developed documented GRADE criteria for evidence. Most guidelines focused on the primary care, and only 27 and 7% included treatment at tertiary and secondary levels, respectively, focused on general practitioners. Conclusion: There is a need for coordinated, and collaborative efforts to generate evidence-based guidelines, facilitate periodic revisions, standardized development process, and the standards for monitoring embedded in the guidelines. A single designated authority for the standard treatment guidelines development and a central web-based repository with free access for clinicians/users will ensure wide access to quality guidelines enhancing acceptance and stewardship.

Implementing a health labour market analysis to address health workforce gaps in a rural region of India.

BACKGROUND: Human Resources for Health (HRH) are essential for making meaningful progress towards universal health coverage (UHC), but health systems in most of the developing countries continue to suffer from serious gaps in health workforce. The Global Strategy on Human Resources for Health-Workforce 2030, adopted in 2016, includes Health Labor Market Analysis (HLMA) as a tool for evidence based health workforce improvements. HLMA offers certain advantages over the traditional approach of workforce planning. In 2018, WHO supported a HLMA exercise in Chhattisgarh, one of the predominantly rural states of India. METHODS: The HLMA included a stakeholder consultation for identifying policy questions relevant to the context. The HLMA focused on state HRH at district-level and below. Mixed methods were used for data collection and analysis. Detailed district-wise data on HRH availability were collected from state's health department. Data were also collected on policies implemented on HRH during the 3 year period after the start of HLMA and changes in health workforce. RESULTS: The state had increased the production of doctors but vacancies persisted until 2018. The availability of doctors and other qualified health workers was uneven with severe shortages of private as well as public HRH in rural areas. In case of nurses, there was a substantial production of nurses, particularly from private schools, however there was a lack of trusted accreditation mechanism and vacancies in public sector persisted alongside unemployment among nurses. Based on the HLMA, pragmatic recommendations were decided and followed up. Over the past 3 years since the HLMA began an additional 4547 health workers including 1141 doctors have been absorbed by the public sector. The vacancies in most of the clinical cadres were brought below 20%. CONCLUSION: The HLMA played an important role in identifying the key HRH gaps and clarifying the underlying issues. The HLMA and the pursuant recommendations were instrumental in development and implementation of appropriate policies to improve rural HRH in Chhattisgarh. This demonstrates important progress on key 2030 Global Strategy milestones of reducing inequalities in access to health workers and improving financing, retention and training of HRH.

Assessing competence of mid-level providers delivering primary health care in India: a clinical vignette-based study in Chhattisgarh state.

BACKGROUND: The global commitment to primary health care (PHC) has been reconfirmed in the declaration of Astana, 2018. India has also seen an upswing in national commitment to implement PHC. Health and wellness centres (HWCs) have been introduced, one at every 5000 population, with the fundamental purpose of bringing a comprehensive range of primary care services closer to where people live. The key addition in each HWC is of a mid-level healthcare provider (MLHP). Nurses were provided a 6-month training to play this role as community health officers (CHOs). But no assessments are available of the clinical competence of this newly inducted cadre for delivering primary care. The current study was aimed at providing an assessment of competence of CHOs in the Indian state of Chhattisgarh. METHODS: The assessment involved a comparison of CHOs with rural medical assistants (RMAs) and medical officers (MO), the two main existing clinical cadres providing primary care in Chhattisgarh. Standardized clinical vignettes were used to measure knowledge and clinical reasoning of providers. Ten ailments were included, based on primary care needs in Chhattisgarh. Each part of clinical vignettes was standardized using expert consultations and standard treatment guidelines. Sample size was adequate to detect 15% difference between scores of different cadres and the assessment covered 132 CHOs, 129 RMAs and 50 MOs. RESULTS: The overall mean scores of CHOs, RMAs and MOs were 50.1%, 63.1% and 68.1%, respectively. They were statistically different (p < 0.05). The adjusted model also confirmed the above pattern. CHOs performed well in clinical management of non-communicable diseases and malaria. CHOs also scored well in clinical knowledge for diagnosis. Around 80% of prescriptions written by CHOs for hypertension and diabetes were found correct. CONCLUSION: The non-physician MLHP cadre of CHOs deployed in rural facilities under the current PHC initiative in India exhibited the potential to manage ambulatory care for illnesses. Continuous training inputs, treatment protocols and medicines are needed to improve performance of MLHPs. Making comprehensive primary care services available close to people is essential to PHC and well-trained mid-level providers will be crucial for making it a reality in developing countries.

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.

Patient safety in graduate curricula and training needs of health workforce in India: A mixed-methods study.

BACKGROUND: Improving quality of health services and providing safe care require well-trained and skilled workforce. The inclusion of components of patient safety in graduate training curricula, followed by adherence to curricula in teaching programs, can improve the quality of health-care services. OBJECTIVES: To review the existing training curricula for five subgroups of health workforce (Allopathic doctors, nurses, laboratory technicians, pharmacists, and nurse midwives) and to document the components and identified variables of patient safety covered. METHODS: A mixed-methods study was conducted during July 2017-March 2018. Data were collected through desk review, field visits, in-depth interviews, self-administered questionnaires, and focused group discussions (FGDs). A total of 24 variables were identified by the experts to review the training curricula. RESULTS: Seven states, 28 institutes, and 42 health-care facilities were visited. A total of 516 staff from different health cadres participated in the study through 54 interviews, 156 self-administered questionnaires, and 24 FGDs. Of 24 patient safety variables considered, 16 were covered in the medical and nursing, 9 in laboratory technician and pharmacist, and 5 in midwives' curricula. The teaching material on the patient safety, for most categories of staff, was not available in consolidated form, and there was no standardization. CONCLUSION: There is a need for the development of comprehensive training material cum operational modules on patient safety, suitably adopted as per the learning needs of different subgroups of health staff. The need for strengthening patient safety has been further underscored as the health workforce is fighting the coronavirus disease 19 (COVID-19) pandemic. The initiatives on patient safety will contribute to improved overall quality of health services, which in turn would advance universal health coverage.

What makes primary healthcare facilities functional, and increases the utilization? Learnings from 12 case studies.

BACKGROUND: The last few decades have witnessed a number of innovative approaches and initiatives to deliver primary healthcare (PHC) services in different parts of India. The lessons from these initiatives can be useful as India aims to strengthen the PHC system through Health and Wellness Centers (HWCs) component under Ayushman Bharat Program, launched in early 2018. MATERIALS AND METHODS: Comparative case study method was adopted to systematically document a few identified initiatives/models delivering the PHC services in India. Desk review was followed by field visits and key informant interviews. Twelve PHC case studies from 14 Indian states, with a focus on equity and "potentially replicable designs" were included from the government as well as the "not-for-profit" sector. The cases studies comprised of initiatives/models having the provision of PHC services, whether exclusively or as part of broader hospital services. The data was collected from May 2016 to March 2017. RESULTS: The "political will" for government facilities and "leadership and motivation" for "not-for-profit" facilities adjudged to contribute towards improved functioning. A comprehensive package of services, functional 'continuity of care' across levels, efforts to meet one or more type of quality standards and limited "intention to availability" gap (or assured provision of promised services) were considered to be associated with increased utilization. A total of 10 lessons and learnings derived from the analysis of these case studies have been summarised. CONCLUSIONS: The case studies in this article highlights the components which makes PHC facilities functional and have potential for increased utilization. The article underscores the need for institutional mechanisms for health system research and innovation hubs at both national and state level in India, for the rapid scale of comprehensive primary healthcare. Lessons can be applied to other low- and middle-income countries intending to deliver comprehensive PHC services to advance towards universal health coverage.

Community action for health in India: evolution, lessons learnt and ways forward to achieve universal health coverage.

The role of civil society and community-based organizations in advancing universal health coverage and meeting the targets of the 2030 Agenda for Sustainable Development has received renewed recognition from major global initiatives. This article documents the evolution and lessons learnt through two decades of experience in India at national, state and district levels. Community and civil society engagement in health services in India began with semi-institutional mechanisms under programmes focused on, for example, HIV/AIDS, tuberculosis, polio and immunization. A formal system of community action for health (CAH) started with the launch of the National Rural Health Mission in 2005. By December 2018, CAH processes were being implemented in 22 states, 353 districts and more than 200 000 villages in India. Successive evaluations have indicated improved performance on various service delivery parameters. One example of CAH is community-based monitoring and planning, which has been continuously expanded and strengthened in Maharashtra since 2007. This involves regular, participatory auditing of public health services, which facilitates the involvement of people in assessing the public health system and demanding improvements. At district level, CAH initiatives are successfully reaching "last-mile" communities. The Self-Employed Women's Association, a cooperative-based organization of women working in the informal sector in Gujarat, has developed community information hubs that empower clients to access government social and health sector services. CAH initiatives in India are now being augmented by regular activities led and/or participated in by civil society organizations. This is contributing to the democratization of community and civil society engagement in health. Additional documentation on CAH and the further formalization of civil society engagement are needed. These developments provide a valuable opportunity both to improve governance and accountability in the health sector and to accelerate progress towards universal health coverage. Lessons learnt may be applicable to other countries in South-East Asia, as well as to most low- and middle-income countries.

Cost-Effectiveness of Therapeutic Use of Safety-Engineered Syringes in Healthcare Facilities in India.

BACKGROUND: Globally, 16 billion injections are administered each year of which 95% are for curative care. India contributes 25-30% of the global injection load. Over 63% of these injections are reportedly unsafe or deemed unnecessary. OBJECTIVES: To assess the incremental cost per quality-adjusted life-year (QALY) gained with the introduction of safety-engineered syringes (SES) as compared to disposable syringes for therapeutic care in India. METHODS: A decision tree was used to compute the volume of needle-stick injuries (NSIs) and reuse episodes among healthcare professionals and the patient population. Subsequently, three separate Markov models were used to compute lifetime costs and QALYs for individuals infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Three SES were evaluated-reuse prevention syringe (RUP), sharp injury prevention (SIP) syringe, and syringes with features of both RUP and SIP. A lifetime study horizon starting from a base year of 2017 was considered appropriate to cover all costs and consequences comprehensively. A systematic review was undertaken to assess the SES effects in terms of reduction in NSIs and reuse episodes. These were then modelled in terms of reduction in transmission of blood-borne infections, life-years and QALYs gained. Future costs and consequences were discounted at the rate of 3%. Incremental cost per QALY gained was computed to assess the cost-effectiveness. A probabilistic sensitivity analysis was undertaken to account for parameter uncertainties. RESULTS: The introduction of RUP, SIP and RUP + SIP syringes in India is estimated to incur an incremental cost of Indian National Rupee (INR) 61,028 (US$939), INR 7,768,215 (US$119,511) and INR 196,135 (US$3017) per QALY gained, respectively. A total of 96,296 HBV, 44,082 HCV and 5632 HIV deaths are estimated to be averted due to RUP in 20 years. RUP has an 84% probability to be cost-effective at a threshold of per capita gross domestic product (GDP). The RUP syringe can become cost saving at a unit price of INR 1.9. Similarly, SIP and RUP + SIP syringes can be cost-effective at a unit price of less than INR 1.2 and INR 5.9, respectively. CONCLUSION: RUP syringes are estimated to be cost-effective in the Indian context. SIP and RUP + SIP syringes are not cost-effective at the current unit prices. Efforts should be made to bring down the price of SES to improve its cost-effectiveness.