|Year : 2016 | Volume
| Issue : 3 | Page : 116-121
A comprehensive review of evolution of human resources for health in public health services in India
Nandini Sharma1, A Venkat Raman2, Charu Kohli1, Pawan Kumar3
1 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Department of Human Resource and Health Systems, Faculty of Management Studies, University of Delhi, New Delhi, India
3 Directorate of Health Services, Govt. of NCT Delhi, New Delhi, India
|Date of Web Publication||7-Oct-2016|
Dr. Charu Kohli
Department of Community Medicine, Maulana Azad Medical College, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Health workers are the most valuable assets of the health system as it is a labor-intensive service industry. There is, however, a continuing shortage of health personnel in the public health services in India which could undermine the country's efforts to fulfill the Millennium Development Goals. Health Policy and Planning has been shaped by the recommendations of various expert committees set up by the Government from time to time. These committees recognized the importance of human resources in health (HRH) and made important recommendations. This paper attempts to comprehensively review the evolution of policies and strategies for the development of HRH in India.
Keywords: Evolution, health sector, human resources, India
|How to cite this article:|
Sharma N, Raman A V, Kohli C, Kumar P. A comprehensive review of evolution of human resources for health in public health services in India. MAMC J Med Sci 2016;2:116-21
|How to cite this URL:|
Sharma N, Raman A V, Kohli C, Kumar P. A comprehensive review of evolution of human resources for health in public health services in India. MAMC J Med Sci [serial online] 2016 [cited 2020 May 25];2:116-21. Available from: http://www.mamcjms.in/text.asp?2016/2/3/116/191663
| Introduction|| |
Human resource (HR) is the most valuable and indispensable resource for any organization, but more so for the health sector which is the most labor-intensive industry. As per the World Health Organization (WHO), the quality of health services, their efficacy, efficiency, and accessibility depend primarily on the performance of those who deliver them. The performance of providers is determined by the policies and practices that define number of staff, their qualifications, deployment, and their working condition. In community-based health care, which relies less on equipment and advanced technology, HR has an even more prominent role and accounts for an even higher proportion of total costs. The formulation of national policies and plans in pursuit of health workforce development requires sound information and evidence. HRs are a strategic capital in any organization, but particularly so in health and other service organizations that are highly dependent on their workforce.
The public health infrastructure has developed over the years in India, and at present, there are 5363 Community Health Centers (CHCs), 25,020 Primary Health Centers (PHCs), and 152,326 Sub Health Center (SHCs). Despite this large network of health facilities, the public health system in India is plagued by many problems - the most important of which are the shortage of staff, resources, and nonavailability of (free) medicines. The shortage of doctors and paramedical staff is more acute in primary care facilities in the rural areas and urban slums. Against the sanctioned strength of 34,750 doctors at the PHCs, 9389 (i.e., 27%) posts are vacant. At CHCs, the shortage is more staggering: 84% of surgeons, 76% of obstetricians and gynecologists, 83% of physicians, and 82% of pediatrician posts are vacant. There is also a shortage of paramedical staff such as radiographers, lab technicians, and pharmacists.
The importance of human resource development (HRD) has also been reflected in the official policy of the WHO since 1976 to encourage the integration of health services with the development of health personnel. There is a general consensus that human resources for health (HRH) has been a neglected component of health systems development in low- and middle-income countries. In the Indian context, it is prudent to examine the historical development of policies and strategies related to HRH to understand the persistent gaps and steps suggested to overcome these.
India is committed to achieve health for all and fulfill the goal for achieving the Millennium Development Goals. Developing capable, motivated, and supported health workers is essential for overcoming bottlenecks to achieve national and global health goals. "Health for all" is not achievable without health sector reforms that incorporate a process of coordinated health and HRD.
As the backbone of the health system, health workers usually account for the largest share of public expenditure on health. Staff salaries alone constitute up to 75% of health expenditure (public health budget) in many low-income countries (in some cases, it may even go up to 90%)., The presence of high-quality, motivated staff is a key aspect of health system performance but also one of the most difficult inputs to ensure., Historically, there has been a major, although misplaced, emphasis on the development of physical, technical, and technological facilities rather than on health workforce development. The lack of attention to HR management (HRM) in health is the result of the fact that most Governments which directly or indirectly fund the majority of health-care expenditure have been primarily concerned with macroeconomic issues, especially size of the workforce rather than the micro-level focus of contemporary HR practices which concentrate on the motivation and performance of the workforce. Thus, HR has never been dealt with separately in the system. In the recent past, however, the National Commission on Macroeconomics and Health has identified HRs as one of the key drivers of the health system. The Commission has noted the shortage of HRH of all categories and made recommendations about it. The HRH issues in India are multi-factorial. Geographic mal-distribution, contribution of female workforce, lack of reliable and comprehensive workforce data are some notable factors. The evolution of public health including the HRs can be viewed largely through various committees set up by the Government. The First Health Survey and Development Committee (Bhore Committee) was constituted during the colonial rule. The various committees set up after the Bhore Committee considered several HR issues, challenges, and laid down guidelines for developing them. In this paper, a brief overview of the committees, the five-year plans - their focus and recommendations related to HRH system of India and exploring the reasons, implementation, and implications of their suggestions and recommendations - is presented.
| A Brief Historical Review of Human Resources for Health in India|| |
As early as the 4th century B.C., Kautilya provided a systematic treatment of the management of HRs, in his treatise titled "Arthashastra." He provided an excellent discussion on staffing and personnel management embracing job descriptions, qualifications for jobs, selection procedure, executive development, incentive systems (Sarasasaama-daana-bheda-danda-catura or Carrot and Stick approach), and performance evaluation. However, there is no evidence of the use of these principles in the health sector.
The first formal health policy in India began to shape before independence when the National Planning Committee was set up by the Indian National Congress in 1938 under the chairmanship of Colonel Santok Singh Sokhey. The subcommittee did a analysis of the health situation in the country and recommended measures for its improvement in their interim report. The Sokhey Committee Report endorsed the recommendations of the Bhore Committee. It had the vision of creating a post of a community health worker for every 900 people and to entrust "people's health in people's hand." It can be considered a stepping stone of HRD to the process of policy making. The need for training large numbers of health workers in community-based settings and focus on personal hygiene, first aid, and simple medical treatment with stress on the social implications of medical and public health work were emphasized. However, due to the political turmoil in Indian politics, its report came much later than the Bhore committee report which brought out the gap in the existing doctor to population ratio.
The first ever formal mechanism for workforce planning was spelled out in the pre-independence era by the Bhore committee. The Joseph Bhore Committee or Health Survey and Development Committee was constituted in 1946 to study the existing health conditions and make recommendations to prevent communicable diseases, promote health, and provide basic health care. The major recommendations of the committee were - to have full-time salaried services of doctors to provide health services to the rural population, prohibit private practice by full-time government doctors, to establish the Department of Social and Preventive Medicine in all medical colleges and postgraduate education in the same to introduce refresher courses for general private practitioners.
The development and deployment of HRH in India over the last six decades have been steered by various Government-commissioned expert committees, namely, the Health Survey and Planning Committee lead by Mudaliar (1961), Chadha Committee (1963), Kartar Singh Committee (1974), Shrivastav Committee (1975), Medical Education and Review Committee led by Mehta (1983), Bajaj Committee (1986), Mukherjee Committee (1995), National Commission on Macroeconomics and Health (2005), and Planning Commission Task Force on Planning for HRH (2007).
In the first five-year plan after independence (1951-1956), vertical programs were initiated to deliver the health services. There were separate sets of workforce with separate job descriptions, recruitment procedures, training, performance appraisal, promotion, and reward in each program. The scope for development, career planning, and gender equity were out of the purview of planning.
In the year 1962, a committee known as the "Health Survey and Planning Committee" or "Mudaliar committee" headed by Dr. AL Mudaliar recommended that the All India Health Services should be created to replace the erstwhile Indian Medical service. It also talked about strengthening of field training of the health personnel. The key recommendations for the development of HRH were:
- PHC medical officers should not be allowed private practice but be given nonpracticing plus public heath allowances together with residential accommodation
- Preference for postgraduate training facilities to be given to those who serve in the rural areas
- Partnership with private practitioners for health programmers and to secure their cooperation for service delivery
- To train a large number of medical officers and other categories of health personnel in public health and to establish schools of public health in all states.
In 1965, a committee to review staffing pattern and financial provision under Family Planning Program, chaired by Shri Mukerjee, was constituted. The purpose was to review the changes required in the staffing pattern and financial provisions as a result of the introduction of the intrauterine contraceptive device (IUCD) in the Family Planning Program. The key recommendations of committee were:
- Part-time workers, wherever necessary to be appointed on payment of an honorarium for motivating and bringing cases for vasectomy and IUCD insertion
- Need of some flexibility in qualification criteria for different categories of personnel, where State Governments could be allowed to frame their own recruitment rules for various categories of personnel
- Imposing compulsory rural service for doctors
- Paying fixed allowance and giving monetary incentive to part-time private medical practitioners working in family planning centers on the basis of performance
- Employment of private practitioners in the sterilization and IUCD program to be given considerable importance.
Subsequently, Chadha Committee formulated in 1963 recommended:
- Integration of health and family planning services through one male and one female multipurpose worker per 10,000 population. However, the recommendation remained unimplemented.
In 1967, the Committee on Integration of Health Services under the chairmanship of Dr. Jungalwalla submitted its report. The key HRM recommendations were:
- Integration of functions, organization, personnel providing these services and their administration from the highest to the lowest levels
- Steps recommended for integration were: Unified cadre, common seniority, recognition of extra qualification, equal pay for equal work, special pay for specialized work, no private practice, and good working conditions.
Further, Kartar Singh Committee in the year 1973 critiqued the separation of functions and recommended the development of male and female multipurpose health workers (MPWs). The MPW scheme was launched afterward. Job descriptions of multipurpose health workers and their supervisors were defined by the committee. Other recommendations were:
- To have at least two doctors (one of them should be a female) in each PHC
- Integrated training for all workers engaged in the field of health, family planning, and nutrition
- A separate training division to be established at the center.
Chadha Committee Report, Kartar Singh Committee Report on Multipurpose Workers, and Srivastava Committee Report on Medical Education and Manpower remained focused on giving recommendations on how the health cadres at the primary level should be distributed and vertical administrative hierarchy would be strengthened. However, in none of the subsequent national plans, the components of HRD suggested by the committees were seen.
During the fifth five-year plan (1974-1979), policymakers realized that the health had to be addressed alongside other development programs. The community health volunteer scheme and the scheme of training and employment of multipurpose workers were to be continued under the Minimum Needs Program. The National Health Policy in 1982 recommended major changes in the health care system including a nationwide chain of epidemiological stations and a decentralized system of health care. The policy document missed out on the importance of a strong referral system and the role of workforce at the suitable levels.
The Bajaj Committee for Health Manpower Planning and Development presented the first ever assessment of HRH availability in India. It recognized that health systems and HRD were isolated from each other across ministries. The committee made projections for rural HRH requirements for the millennium along with recommendations for building HR capacity in educational institutions. To ensure quality in health services, the Bajaj Committee recommended a competency-based curriculum, refresher and bridge courses, in-service training, career structures for all categories, and uniform pay scales across the country. It also recommended cadre-wise coordinated planning for HRH production and the establishment of a University of Health Sciences in each state during the eighth plan as advocated earlier by the Medical Education and Review Committee in 1983. It recommended the formulation of a National Policy on Education in Health Sciences (Medical and Health Education Policy). It also recommended that District Institutes of Education and Training should develop integrated training modules for various categories of allied health professionals.
Some of the key recommendations were:
- Health manpower cells may be created at the center and state level to coordinate the implementation of health workforce policy
- Estimation of the requirements of various categories of health personnel up to the CHC level
- Need for equal concern for all categories of health workforce
- Uniform guidelines for recruitment of health personnel
- Preparation of job description for all categories
- Regular review with continual evolution of allied health professionals
- To draw up a career structure for all categories
- To continually review keeping in line with emerging and evolving health care strategies and operations and standardized quality of supervision
- In addition to the assessment of skills and performance, the supervisors were to assess the skills acquired during training courses and any inadequacy was to be reported to the educational institutions for further review of curriculum and facilities for training modalities.
The Seventh Plan (1985-1990) restated that the rural health program and the three-tier health services system need to be strengthened and that the government had to make up for the deficiencies in personnel, equipment, and facilities. The Eighth Plan (1992-1997) distinctly encouraged private initiatives, private hospitals, clinics, and suitable returns from tax incentives.
The Reproductive and Child Health program started in 1997 following the International Conference on Population development held in Cairo in 1994 also failed to involve or mobilize the required HRs for the development of health and the health sector as a whole. Both the Ninth (1997-2002) and tenth five-year plans (2002-2007) highlighted the importance of the role of decentralization but did not state how this will be achieved. The National Health Policy (2002) includes all that are wanted from a progressive document but again lacks the focus on HRH.
The National Commission on Macroeconomics and Health identified HRs as one of the key drivers of the health system. The commission noted the shortage of HRH of all categories, lack of teaching faculty, low quality of instruction and skill acquisition, and neglect of community medicine. The key recommendations for HRs include:
- Training of existing rural medical practitioners over 3 years
- Establishment of six School of Public Health besides upgrading the existing ones
- Need for establishment of a Commission for HRD and Medical and Health Education for promoting excellence in health care and HRH
- Introduction of a system of re-registration of doctors and nurses once every 5 years and linking reregistration of doctors and nurses with a minimum number of hours of Continuing Medical Education
- Establishment of the All-India cadre of public health on the lines of the Indian Administrative Services
- Incentives-financial and nonfinancial to be given for attracting medical teachers to join and continue in pre- and para-clinical specialties in medical colleges
- To increase non-MBBS postgraduate seats in these specialties
- Multiskilling of MBBS doctors with 9-month training at the district hospitals in the scarce specialties.
| National Rural Health Mission|| |
It was evident that the lack of community ownership of public health programs impacts efficiency, accountability, and effectiveness. To overcome these shortcomings in the existing health services and to provide effective health care services to the rural population, the National Rural Health Mission (NRHM) was launched in the year 2005. Many of the missing components of HRM could be seen in this document for the first time in the history of Indian policy making.
The aims of the NRHM included optimization of health workforce, decentralization and district management of health programs, community participation and ownership of assets and induction of management and financial personnel in district health system in the selected 18 states. Provision of a community health worker named Accredited Social Health Activist (ASHA) in each village is one of its key components. Its core strategies included the formulation of transparent policies for deployment and career development of HRH. For the first time, who and how's of the mission were clearly chalked out in the program implementation plan.
The state health directorates were proposed to have a full-fledged HR department with specialized staff and dedicated budget administrative expenses. The salary structure of health personnel was based on the standards followed for the entire state, i.e., all State Government departments, but there was a minimal financial incentive for the health care professional working in rural, remote, and tribal areas, that too in some of the states and not all states. Nonpracticing allowance rule was formulated as PHC medical officers would not be allowed the private practice but be given nonpracticing plus public heath allowances together with residential accommodation. There was a provision that preference for postgraduate training facilities to be given to those who served in the rural areas. It focused on the need for partnership with private practitioners and to secure their cooperation for service delivery and to train a large number of medical officers and other categories of health personnel in public health and establish schools of public health in all states. States have to rely on contractual employment to solve the shortage of workforce. Under the NRHM, contractual appointments to the extent of 14% have somewhat reduced the deficit of health workforce.
The High-Level Expert Group on Universal Health Coverage acknowledged and endorsed the comprehensive and critical recommendations made by these earlier expert bodies. While central and state leadership in health ministry may not have always adopted or implemented the recommendations of these expert committees, their suggested rationale and norms continue to be the basis for HRH planning and formulation of standards.
The above findings are consistent with the previous reports that although strategic importance is given to HRH, it is mostly without a clear vision, approach, and methodology. Ever increasing requirement and shortage of skilled health workforce are constantly increasing the gap between demand and supply which is a major growth constraint.
In its report on HRH, the WHO also recommended an urgent need of commitment and action to strengthen HRH sector. More investment is needed to retain staff and in their education and training for skill building. Accountability of HRH to all stakeholders is desired. Some of the steps suggested were continuous development programs for educators, involvement of all stakeholders in curriculum planning, flexible admission criteria, and accreditation of health professional education. Evidence-based planning and a reliable information management system are required for a sustainable health care delivery system.
The challenges and solutions for HRH as per WHO report are as follows.
- Migration of health workers inside and outside public health sector is a great obstacle
- Despite the fact that large numbers of health workers are produced from training institutions across India every year, it had not translated into any significant increase in their availability in the public health system, especially in the rural areas
- Inadequate leadership to put across issues of HRM in health sector and take informed decisions
- Lack of career planning and development policies that attract workers toward public health system
- Lack of better environment for working and learning
- No research on HRM in health so that evidence-based decisions can be taken.
- HRH should be considered as a local issue depending on the needs of the local area. The HRM rules should be made keeping in consideration local health needs and availability of resources
- Uniform and clear regulatory rules should be made for HRM
- Financial incentives should be provided in certain difficult situations such as geographical and difficult conditions
- Along with finances, better accommodation, working conditions, career planning, and performance-based recognition should be considered for health workforce motivation and sustainability
- Reforms are, therefore, a felt need, and it is increasingly recognized that poor HRM practices remain a dominant constraint for the reforms in health services.
| Conclusion|| |
The above description summarizes the evolution of HRH in public health in India through the recommendations of various committees. The evolution, so far, suggests that various committees have stressed on the importance of HRH and given recommendations for their development. Most of these recommendations remained unfulfilled for a long time. The WHO 2014 meeting on HRM in developing countries listed the challenges and solutions which were more or less what had been done by the various committees so far. However, recently, in 2007 and again in 2010, the Government of India formulated the Indian Public Health Standards (IPHS) and streamlined the requirements of physical infrastructure based on population and HRH requirements for health facilities ranging from the grassroots level SHCs, primary care level PHCs, first referral level CHCs, as well as hospitals with bed strengths of 31-50, 51-100, 101-200, 201-300, and 301-500 respectively. The IPHS (2010) norms are for HRH as well as for equipment, drugs, and service delivery. This could lead to the much-desired development of HRH in the public health services in India.
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Conflicts of interest
There are no conflicts of interest.
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