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Health workforce in India: opportunities and challenges

Adequate availability of appropriate health workforce is a necessary pre-requisite for achieving desired health outcomes in any country. World Health Organization (WHO) defines health workforce as “the stock of all individuals engaged in the promotion, protection or improvement of population health”. This includes both public and private sectors and different domains of health systems, such as curative and preventive care, nonpersonal public health interventions, disease prevention, health promotion services, research, management and support services. 1 Available estimates show that density of health workforce in India is much below the norms of 22.8 skilled professionals per 10000 population as recommended by the WHO. 2,3 In developing countries like India the shortage of workforce in health system is a reality. Many countries face the problems of composition and its distribution across various geographical areas and population groups. The last decade witnessed a significant change in the size and composition of health workforce in India. The health sector reforms undertaken during the decade, particularly with the launch of the National Rural Health Mission (NRHM), subsequently renamed as the National Health Mission (NHM) have emphasized on strengthening health workforce in the government health system. 4,5 Under the NRHM, both central and state governments initiated strategies towards appointment of doctors in public health facilities in the rural areas. In order to bridge the gap in health workforce in rural areas, most state governments made contractual arrangements with private health sector and non-governmental organizations (NGOs). The decade also witnessed a rapid increase in the medical, nursing and paramedical institutions as well as admission capacity in various disciplines.


INTRODUCTION
Adequate availability of appropriate health workforce is a necessary pre-requisite for achieving desired health outcomes in any country. World Health Organization (WHO) defines health workforce as "the stock of all individuals engaged in the promotion, protection or improvement of population health". This includes both public and private sectors and different domains of health systems, such as curative and preventive care, nonpersonal public health interventions, disease prevention, health promotion services, research, management and support services. 1 Available estimates show that density of health workforce in India is much below the norms of 22.8 skilled professionals per 10000 population as recommended by the WHO. 2,3 In developing countries like India the shortage of workforce in health system is a reality. Many countries face the problems of composition and its distribution across various geographical areas and population groups.
The last decade witnessed a significant change in the size and composition of health workforce in India. The health sector reforms undertaken during the decade, particularly with the launch of the National Rural Health Mission (NRHM), subsequently renamed as the National Health Mission (NHM) have emphasized on strengthening health workforce in the government health system. 4,5 Under the NRHM, both central and state governments initiated strategies towards appointment of doctors in public health facilities in the rural areas. In order to bridge the gap in health workforce in rural areas, most state governments made contractual arrangements with private health sector and non-governmental organizations (NGOs). The decade also witnessed a rapid increase in the medical, nursing and paramedical institutions as well as admission capacity in various disciplines.
Health workforce in India comprise of a range of personnel who delivers health services in various specialties' of medicines which broadly include allopathic doctors, AYUSH doctors (comprising dentists, nurses, auxillary midwives, pharmacists, technicians and allied health personnel, community health workers, yoga and naturopathy, registered medical practitioners (RMPs), traditional medical practitioners and healers. Allopathic system consists of physicians, surgeons, specialists and medical graduates with a bachelor's or postgraduate specialist diploma or degree, who registered with the Medical Council of India (MCI). Dentists hold a bachelor's or postgraduate degree or specialist diplomas are registered with the Dental Council of India (DCI). AYUSH doctors who are an integral part of health workforce hold bachelor or postgraduate degree in AYUSH and are registered with the Central Council of Indian Medicine or the Central Council of Homoeopathy, and are authorized to dispense medicines and conduct surgery using their respective fields of specialization. 2,3,6 RMPs act as the first point of contact for treatment of a significant proportion of population living in rural and far flung areas. 7 Nurses have a diploma in general nursing and midwifery or a bachelor's degree or a postgraduate degree registered with the Indian Nursing Council (INC). Another group of health workforce consists of auxiliary nurses and midwives (ANMs), who work as subordinates to the main nurse, possess a diploma in auxiliary nurse midwifery. Also there are also community health workers who after 10 years of formal education and undergo a short training course. 7 Other categories include physiotherapists, diagnostic and other technicians with varied levels of diploma and certificate perform vital activities as healthcare workers.

METHODS
This paper is based on review of the latest information available through government documents; websites and studies related of the health workforce in India. Data on registered health professionals were collected from the websites of MCI, DCI, INC, Pharmacy Council of India, Indian Association of Physiotherapists, and the Ministry of Health and Family Welfare (MOHFW). Pertinently, these data suffer from various deficiencies like duplication of registrations, delisting of inactive workforce or those not available for work due to migration, disability, death etc. The existing publications of MOHFW provides number of major categories of health workforce namely, doctors, surgeons, AYUSH doctors, dentist, nurses, pharmacists and community health workers employed in the public health system. However, data related to health workforce in the private sector is seldom available in the public domain. Two major sources of information on health workforce actively employed in the health sector are available through census of India and the surveys of National Sample Survey Organization (NSSO). These sources classify the workforce by the national industrial classification (NIC) and national classification of occupation (NCO) and are updated with international systems. The estimates of health workforce based on these sources undertaken by recent studies have been used extensively.

Size and composition
Currently there are no reliable and systematic information on the size and composition of health workforce in India and prevailing estimates were based on census of India and surveys of NSSO. Existing studies have shown a significant change in the size and composition of health workforce in India in the last decade. Motkuri and Mishra (2018) estimated the size of workforce in India based on NIC of workers for the past three census years. 8 According to their estimate there were 1.9 million workers engaged in health sector in 1991 that has increased to 2.35 million in 2001 and 4.6 million in 2011 ( Table 1). The addition to total workforce in health sector was only 0.45 million in 2001, but there was rapid increase in health workforce during 2001-2011 which might be due to declining population growth in the decade.

Density of health workforce
Rao et al (2012) estimated India's health workforce density of 20 workers per 10000 populations in 2005. 6 The study based on NSSO (2011-2012) data estimated the density of 20.9 workers per 10000 population in India. 9 After adjusting for the right qualifications, density of health workforce reduced to 9.1 workers per 10000 population. Karan et al (2019) in their broad estimate of health workers including allied health professionals and support staff showed the density of doctors, nurses and midwives per 10 000 population as 20.6 according to the NSSO data and 26.7 based on the registry data. 7 All these estimates showed that country is fall short of WHO's recommendation of the minimum threshold of 22.8 skilled health professionals per 10 000 population. WHO, has revised the minimum need as 44.5 health professionals per 10 000 population. 3 Nair KS. Int J Community Med Public Health. 2019 Oct;6(10):4596-4604 International Journal of Community Medicine and Public Health | October 2019 | Vol 6 | Issue 10 Page 4599

Regional variations
Regional distribution of health workforce reveals a huge variation across various states in India. Table 3 shows the number of health workers available per 1000 population based on NSSO data 2011-12 in different states in India. The estimates show that the density of doctors including dental and AYUSH practitioners per 10,000 population is much lower in states like Assam, Bihar, Himachal Pradesh Jharkhand and Rajasthan (Table  3). While Delhi recorded highest density of doctors (34), Kerala has recorded highest density of nurses and midwife (38).

Public-private distribution
Distribution of health workforce across the country shows that a huge share of them is employed in the private sector. The share of private sector among allopathic physicians, AYUSH and dental practitioners is huge in comparison to nurses and other categories. In contrast to public sector, India's private sector consists of wide range of service providers ranging from individual practitioners to for-profit hospitals, not-for-profit hospitals, non-government organizations, charitable trust institutions. 10,11 The estimate based on NSSO data for 2016 shows almost 53% of health workforce in the private sector is self-employed. More than 80% of doctors and 70% of nurses and midwives were employed in the private sector ( Figure 1).

Rural-urban distribution
There is disproportionately higher concentration of health work force in urban areas. While rural areas constitute about 71% of the population in 2016, only 36% of health workforce was available in rural areas ( Figure 2).

HEALTH WORKFORCE SUPPLY
Last decade witnessed a steady expansion in medical and dental education in India. Presently India has 476 medical colleges, 313 dental colleges for bachelor and 249 colleges for masters of dental surgery (Figure 3). 12 Over the last two and a half decades, students' admissions to medical colleges increased from 22438 in 1991 to 52,646 in 2017. 12 Admissions in dental colleges' increased from 3100 to 33293 during the same period. As far as AYUSH

DISCUSSION
Despite manifold increase in supply of health workforce, India faces a huge shortage of health workforce particularly doctors and specialist in the rural areas of many states which is evident from the vacancy positions in the primary health system. 13,14 Existing studies in India have also explored the attitudes of medical students and in-service health workers towards rural service, and the factors at the individual level that act in favour of retention of health workers in rural areas. [15][16][17] Findings from these studies suggest that rural upbringing; personal values of service, professional interests, co-location with spouses, and availability of education for children are factors at the individual level that influence healthworker retention in rural areas. Poor financial remuneration, lack of good clinical infrastructure in rural areas, and organizational policies and management are some of the key challenges in rural retention of health workers. Studies have established that decision to join rural health service were strongly associated with rural background and attachment with community. 16 Yet, these decisions were challenged by factors such as poor working and living conditions in rural areas, low salary and incentives, and lack of professional growth and appreciation. In order to attract and retain health workforce in rural health systems many initiatives have been introduced by states. Preference in postgraduate admission for those serving in rural areas has been incorporated in the rules of a large number of states. This seems to be a very effective method of attracting doctors to rural areas for a fixed period as PG admission has been a priority for many young doctors. Increased remuneration to doctors willing to serve in rural areas has also been a principle followed in states with good results. Another initiative was identifying health facilities which are located at difficult or inaccessible places in every state and is introducing incentives for staff working there.
The continuous efforts at skill development among the ASHA's and systems of getting them priority admission to ANM and nursing schools will be able to secure resident health workers in remote areas. New courses like the 18-week emergency obstetric and life-saving anesthetist skills and training programs to skill MBBS doctors with select specialist skills are innovative solutions to find specialist skills for rural areas.
There are criticisms against the present medical education system from various corners with respect to imparting knowledge, acquisition of professionals' skills, attitudes, and ethics and value. [18][19][20][21][22] Most part of teaching and training are at the tertiary care setting without exposure to rural and community settings. Quality of medical education is influenced many factors such as its setting, quality of the students, expertise of faculty and teaching methods, course curriculum, evaluation systems, teaching learning environment and the management of the institution. [18][19][20] The present education system is plagued with issues like low student-teacher ratios, inappropriate pedagogy, obsolete and irrelevant syllabi, inadequate library and online resources, substandard teaching faculty, lack of periodic appraisal of faculty and declining academic autonomy. Further, lack of skill and competence based training and inadequate emphasis on critical thinking has resulted in producing undergraduates who are incapable of delivering appropriate care. Commercialization of medical education and mushrooming of for-profit medical education institutions have further added to the complexities. Nevertheless, the government's effort to medical education reforms including initiatives to teach within the community settings, reservations for marginalized communities and harnessing of local and rural talent, changes to the medical curriculum, formal training of teachers, improvements in teaching-learning methods, modification of the examination systems, reorganization of universities, compulsory rural service, etc., have not produced any significant improvements in the health system, Privatization of medical education helped to overcome the inadequacies of the training capacity in the public sector, but it has also raised issues related to the quality of medical education. With expansion of medical educational infrastructures, consistent increase in health workforce production, vacancies in government health facilities in rural areas remain unfilled. There are issues related to gross inequality in the distribution of the educational institutions in few states as these institutions are primarily clustered in few states where health workforce shortages are relatively less. There is also mismatch between production of health workforce and distribution in public health facilities within states which suggests that urgent need to adopt sustained and innovative strategies to address the current healthworkforce crisis.
Migration of health workforce also depletes the available stock as well as availability of teaching staff which further hinders the production of medical professionals. 23,24 India has been the biggest exporter of physicians, accounting for about 4.9% of American and nearly 10 % of British Physicians. Nearly 54% of medical students who graduated from All India Institute of Medical Sciences (AIIMS) during 1989-2000 now reside outside India. 24 Though considerable information exists on the number of doctors emigrating from India to other countries, adequate information is not available on quality of those medical professionals who migrate, and compared to those who remain.
The existing inadequacies in production of different categories of health workforce in states have created significant inequalities in distribution. The states with poor health outcomes recorded a greater shortfall in the number of health workers which highlights the urgent action to develop and implement high quality, evidencebased health workforce development plans; Privatization of medical education in India has not yielded its intended outcomes. In order to improve quality of medical education steps like certification/ accreditation of medical educational institutions, fine tuning syllabus, training in decentralized community settings are necessary. To improve retention of workers in rural areas, recruitment of right health workforce through community structure has the most potential to serve the community needs. Other initiatives which were introduced under the NRHM like performance based incentives, rewards, social recognition, scholarships and bank loan facilities for those committed to service in rural and remote areas need to be continued. Career progression of manpower should be given due emphasis which can motivate them to work in rural areas. Strategies such as task shifting, multi skilling, training, and development of multidisciplinary team should be adopted to meet the holistic needs of population. Initiation of courses in areas of public health and rural health services should be conducted on priority basis. Finally implementation of continuing medical education program, computer networking of training institutions, promotion of IT-based e-health, teleconsultancy, tele-radiology and tele-pathology should be promoted.

CONCLUSION
Post NRHM witnessed a rapid increase in number of medical institutions and admission capacities across states. Existing estimates suggest that India does not meet the standard requirements of skilled workforce in the health system. There has been a severe shortage of health workforce in rural areas and challenges remain in bringing qualified human resources to rural, remote and underserved areas. Apart from taking efforts to increase numerical availability of human resources in rural areas across states with poor health outcomes, it is imminent to strengthen competencies of these workers at all levels.