Human Resources for Health (HRH) is an important building block in health systems, fundamental for attaining Universal Health Coverage (UHC) and several Sustainable Development Goals (SDGs). The High-Level Commission on Health and Employment and Economic Growth constituted by the United Nations in 2016 highlighted that investment in health systems, including investment in healthcare workers, to improve health outcomes, has multiple benefits within and beyond the health sector.
Today several low- and middle-income countries (LMICs) face an acute shortage of trained and well-performing health workforce, precisely because of a sustained under-investment in health, including of the health workforce, in these countries. Our recent study ‘Size, composition and distribution of health workforce in India: why, and where to invest?’ explains the reasons for such shortages, highlights that the use of some national datasets can lead to a very significant over estimate of the actual health workforce, and identifies the need for up-scaling investment in several areas in order to strengthen the HRH situation in India.
Why is there an acute shortage in the health workforce?
Our study highlighted that the actual size of the active health workforce in India is estimated to be only a little more than half of the number reflected by registration councils of doctors and nurses/midwives. This means that the density of the active health workforce in India is less than one-third of the WHO benchmark of 44.5 health workers per 10,000 persons estimated to sustain UHC.
Why this shortage? There are several reasons. First of all, as we highlight in the paper, total numbers of annual new medical graduates (doctors) and nurses/midwives in comparison to the population size are significantly lower in India compared with those in Organisation for Economic Cooperation and Development (OECD) countries, and also several countries in Asia such as China, Thailand and Sri Lanka. India has currently a little over 500 medical colleges and 7,000 nursing institutes producing on average 9 doctors and 4 nurses/midwives per 100,000 population annually. The same numbers are as high as 44 and 13 respectively in OECD countries. India, hence, needs to invest in opening new institutions for producing an increased number of health professionals.
Secondly, the Periodic Labour Force Survey (PLFS) 2018-19 data reflects that more than 30% of the doctors and more than 50% of the nurses with adequate qualifications are not part of the current health workforce. There are several reasons why qualified health professionals are not part of the current health workforce. Past studies ‘So many, yet few: Human resource for health in India’ and ‘Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data’ noted that the registration council’s data are not regularly updated to account for attrition of qualified health professionals due to migration, death or retirement. Also, there are issues with double counting in the registration data, resulting in an overestimation of the total stock of health professionals in the country.
However, one of the most important reasons for the acute shortage in the health workforce in India is labour market attrition of qualified health professionals. We have estimated that approximately 30% of individuals with a medical degree and more than 60% of individuals with a diploma in medicine are not part of the current health workforce. A small proportion (6-8%) of the out-of-workforce personnel are unemployed and looking for jobs. However, a large proportion (25-30%) of the qualified health professionals do not report themselves as part of the labour force. An overwhelming proportion (65-70%) of these out-of-labour-force health professionals are women aged 35 years and above or individuals above 60 years of age.
If efforts are made to bring back even 50% of the out-of-workforce health professionals into the workforce, by providing them with an improved wok environment, increased retirement age, posting in a place of choice, flexible work hours, etc., the current shortage in the qualified health force in India could be bridged to a large extent.
Another area of concern for HRH in India has been the highly skewed distribution of the health workforce across rural and urban areas, small and large cities, and also across public and private health facilities. Large concentrations of health workers in big cities and in the private sector has left poor, rural and less-advantaged populations deprived of accessing quality health care.
Our analysis leads us to conclude that India needs major policy interventions along with big investment in HRH to make access to health more equitable in India. India needs to invest in opening new educational institutions for doctors and nurses, along with developing other necessary health infrastructure at a much higher scale. Enhanced investment is also required for training and skilling/re-skilling medically qualified personnel currently working in other areas of the labor market or not in employment, to bring them back into the health workforce. Such investment in India has the potential to bring multiple returns within and beyond the health sector, including employment and economic growth.